RUC 1The Evolution of Nursing chap. 1

It was also in the early 1950s that the National Association of Colored Graduate Nurses (NACGN) went out of existence.

This was the organization that fought for integration of the African-American nurse into the ANA. From 1916 to 1948, African-American nurses in the South were barred from membership in the ANA because of segregation laws in the Southern states. In the 1940s, the NACGN began to wage an all-out war against discrimination by the Southern constituents of the ANA. The NACGN chose as its central issue the route to membership in ANA. This issue was raised by the NACGN on the floor at every national convention of the ANA, and it evoked strong opposition from the Southern state constituents. Speaking from the floor of the House of Delegates at the 1946 convention in Atlantic City, a white nurse from Georgia referred to African-American nurses as "our darkies." Immediately a motion was passed to strike the reference from the record. However, this comment caused an uproar, and the African-American nurses who were barred from membership in the Southern states started the wheels turning to bypass the states and join ANA directly. This arrangement, known as individual membership, was put into effect in 1948. With the establishment of individual membership, African-American nurses in the South could bypass their states and become members of the ANA. This type of individual membership continued until all barriers had been dropped in the early 1960s (Carnegie, 1995).

Another outcome of the Medicare legislation was the home health movement.

To receive Medicare reimbursement for home health services, patients had to have (1) home-bound status; (2) a need for part-time or intermittent, skilled nursing care; (3) a medically reasonably and necessary need for treatment; and (4) a plan of care authorized by a physician. Home health agencies were established and began to employ increasing numbers of nurses. The number of home health agencies began to grow in the mid-1960s, and as a result of Medicare reimbursement and other influences, including a growing older adult population, advances in medical technology, and public demand for increased access to health care, the home health industry continued unprecedented growth into the 1990s. Home health was one of the first employment settings that provided nurses the opportunity to work weekdays only.

In 1921

the federal government recognized the need to improve the health of women and children and passed the Sheppard-Towner Act, one of the first pieces of federal legislation passed to provide funds to assist in the care of special populations (Oermann, 1997). This funding provided public health nurses with resources to promote the health and well-being of women, infants, and children.

Health departments employed public health nurses

to provide the bulk of the care needed by children and pregnant women in the Medicaid population. Services provided by these nurses included family planning, well-child assessments, immunizations, and prenatal care. A physician assigned as the district health officer supervised the nurses. Without the public health nurses and local health departments, many women and children in the inner city areas and rural communities would have been without access to basic health care.

As the concern over increasing health care costs heightened

use of ambulatory services increased and enrollment in health maintenance organizations grew. Advanced nurse practitioners increased in popularity as cost-effective providers of primary and preventive health care. A growing number of nurses moved from the hospital setting into the community to practice in programs, such as hospice and home health. Consumers began to demand bans on unhealthy activities, such as smoking in public. Health education became more important as consumers were encouraged to take responsibility for their own care (Stanhope and Lancaster, 2008). Even the terminology changed; the individual once known as the patient became known as the client or consumer and was afforded respect as a person who purchases a service.

Nursing in the 1990s

...

BOX 1-1 Important Events in the Evolution of Nursing

1751 The Pennsylvania Hospital is the first hospital established in America. 1798 The U.S. Marine Hospital Service comes into being by an act of Congress on July 16. It is renamed the U.S. Public Health Service in 1912. 1840 Two African-American women, Mary Williams and Frances Rose, who founded Nursing Sisters of the Holy Cross, are listed as nurses in the City of Baltimore Directory. 1851 Florence Nightingale (1820-1910) attends Kaiserswerth to train as a nurse. 1854 During the Crimean War, Florence Nightingale transforms the image of nursing. Mary Seacole, a black woman from Jamaica, West Indies, nurses during the same time. 1861 The outbreak of the Civil War causes African-American women to volunteer as nurses. Among these women are Harriet Tubman, Sojourner Truth, and Susie King Taylor. 1872 Another school of nursing opens in the United States: the New England Hospital for Women and Children in Boston, Massachusetts. 1873 Linda Richards is responsible for designing a written patient record and physician's order system—the first in a hospital. 1879 Mary Mahoney, the first trained African-American nurse, graduates from the New England Hospital for Women and Children in Boston, Massachusetts. 1882 The American Red Cross is established by Clara Barton. 1886 The Visiting Nurses Association (VNA) is started in Philadelphia; Spelman College, Atlanta, Georgia, establishes the first diploma nursing program for African-Americans. 1893 Lillian Wald and Mary Brewster establish the Henry Street Visiting Nurse Service in New York. 1896 The Nurses' Associated Alumnae of the United States and Canada is established 1898 Namahyoke Curtis, an untrained African-American nurse, is assigned by the War Department as a contract nurse in the Spanish-American War. 1899 The International Council of Nurses (ICN) was founded. 1900 The first issue of the American Journal of Nursing is published. 1901 The Army Nurse Corps is established under the Army Reorganization Act. 1902 School of nursing is established in New York City by Linda Rogers. 1903 The first nurse practice acts are passed, and North Carolina is the first state to implement registration of nurses. 1908 The National Association of Colored Graduate Nurses is founded; it is dissolved in 1951. 1909 Ludie Andrews sues the Georgia State Board of Nurse Examiners to secure African-American nurses the right to take the state board examination and become licensed; she wins in 1920. 1911 The American Nurses Association (ANA) is established. 1912 The U.S. Public Health Service and the National League for Nursing (NLN) are established. 1918 Eighteen black nurses are admitted to the Army Nurse Corps after the armistice is signed ending World War I. 1919 Public Health Nursing is written by Mary S. Gardner. A public health nursing program is started at the University of Michigan. 1921 The Sheppard-Towner Act is passed providing federal aid for maternal and child health care. 1922 Sigma Theta Tau is founded (becomes the International Honor Society of Nursing in 1985). 1923 The Goldmark Report criticizes the inadequacies of hospital-based nursing schools and recommends increased educational standards. 1924 The U.S. Indian Bureau Nursing Service is founded by Eleanor Gregg. 1925 The Frontier Nursing Service is founded by Mary Breckenridge. 1935 The Social Security Act is passed. 1937 Federal appropriations for cancer, venereal diseases, tuberculosis, and mental health are begun. 1939 World War II begins. 1941 The U.S. Army establishes a quota of 56 African-American nurses for admission to the Army Nurse Corps. The Nurse Training Act is passed. 1943 An amendment to the Nurse Training bill is passed that bars racial bias. 1945 The U.S. Navy drops the color bar and admits four African-American nurses. 4 5 1946 Nurses are classified as professionals by the U.S. Civil Service Commission. The Hospital Survey and Construction Act (Hill-Burton) is passed. 1948 The Brown Report discusses the future of nursing 1948 Estelle Osborne is the first African-American nurse elected to the board of the ANA. The ANA votes individual membership to all African-American nurses excluded from any state association. 1949 M. Elizabeth Carnegie is the first African-American nurse to be elected to the board of a state association (Florida). 1950 The Code for Professional Nurses is published by the ANA. 1952 National nursing organizations are reorganized from six to two: ANA and NLN. 1954 The Supreme Court decision Brown v. Board of Education asserts that "separate educational facilities are inherently unequal." 1965 The Social Security Amendment includes Medicare and Medicaid. 1971 The National Black Nurses Association is organized. 1973 The ANA forms the American Academy of Nursing. 1974 The American Assembly of Men in Nursing was founded. 1978 Barbara Nichols is the first African-American nurse elected president of the ANA. M. Elizabeth Carnegie, an African-American nurse, is elected president of the American Academy of Nursing. 1979 Brigadier General Hazel Johnson Brown is the first African-American chief of the Army Nurse Corps. 1985 Vernice Ferguson, an African-American nurse, is elected president of Sigma Theta Tau International. 1986 The Association of Black Nursing Faculty is founded by Dr. Sally Tucker Allen. 1990 Congress proclaims March 10 as Harriet Tubman Day in the United States, honoring her as a brave African-American freedom fighter and nurse during the Civil War. The Bloodborne Pathogen Standard is established by OSHA. 1991 Healthy People 2000 is published. 1993 The National Center for Nursing Research is upgraded to the National Institute of Nursing Research within the National Institutes of Health. 1994 NCLEX-RN®, a computerized nurse-licensing examination, is introduced. 1996 The Commission on Collegiate Nursing Education is established as an agency devoted exclusively to the accreditation of baccalaureate and graduate-degree nursing programs. 1999 Beverly Malone, the second African-American president of the ANA, is named Deputy Assistant Secretary for Health, Department of Health and Human Services, Office of Public Health and Science. The IOM releases its landmark report: To Err Is Human: Building a Safer Health System. 2000 M. Elizabeth Carnegie is inducted into the ANA Hall of Fame. The American Nurses Credentialing Center gives its first psychiatric mental health nurse practitioner examination. Healthy People 2010 is published. AACN reports a faculty vacancy rate of 7.4% among the 220 nursing schools that responded to a survey. According to the AACN, the average age of full-time faculty is more than 50 years old; average age of doctorally prepared professors is 55.9. 2001 Beverly Malone is appointed General Secretary, Royal College of Nursing, London. Health Care Financing Administration (HCFA) becomes Centers for Medicare & Medicaid Services (CMS). 2002 Johnson and Johnson Health Care Systems, Inc. launches The Future of Nursing, a national publicity campaign to address the nursing shortage. 2002 To address the shortage of nurses the Nurse Reinvestment Act is signed into law by President George W. Bush. 2002 Significant funding is obtained for geriatric nursing initiatives. 2003 The American Nurses Foundation launches an "Investment in Nursing" Campaign to deal with the nursing shortage. 2003 IOM report Keeping Patients Safe: Transforming the Work Environment of Nurses is released. 2003 AACN White Paper on the Role of the Clinical Nurse Leader. 5 6 2005 CCNE decides that only programs that offer practice doctoral degrees with the Doctor of Nursing Practice (DNP) title will be eligible for CCNE accreditation. 2005 NLN offers and certifies the first national certification for nurse educators; the initials CNE may be placed behind the names of those certified. 2006 AACN approves essentials of doctoral education for advanced nursing practice (DNP) (www.aacn.nche.edu/DNP/pdf/Essentials.pdf). 2007 Commission on Nurse Certification, an autonomous arm of AACN, began certifying clinical nurse leaders (CNLs). 2008 Commission on Collegiate Nursing Education begins accrediting DNP programs.

Public health programs struggled to survive as counties and states cut health department budgets

A landmark study conducted by the Institute of Medicine (IOM) in 1988, titled The Future of Public Health, indicated a dismal picture for public health. The study determined that public health had moved away from its traditional role and core functions and that no strategy was in place to bring public health back to its original purpose (Stanhope and Lancaster, 2008). Inadequate funding for public health continues to be a problem; however, it is hoped that soon public health will be restored to its original function and purpose.

Professional nurse

A specially trained professional that addresses the humanistic and holistic needs of patients, families, and environments and provides responses to patterns and/or needs of patients, families, and communities to actual and potential health problems. The professional nurse has diverse roles, such as health care provider, client advocate, educator, care coordinator, primary care practitioner, and change agent (Katz et al, 2009).

EARLY CIVILIZATION Egypt

Ancient Egyptians are noted for their accomplishments in health care at an early period in civilization. They were the first to use the concept of suture in repairing wounds. They also were the first to be recorded as developing community planning that resulted in a decrease in 34 public health problems. One of the main early public health problems was the spread of disease through contaminated water sources. Specific laws on cleanliness, food use and preservation, drinking, exercise, and sexual relations were developed. Health beliefs of Egyptians determined preventive measures taken and personal health behaviors practiced. These health behaviors were usually carried out to accommodate the gods. Some behaviors were also practiced expressly to appease the spirits of the dead (Kalisch and Kalisch, 2003). The Egyptians developed the calendar and writing, which initiated recorded history. The oldest records date back to the sixteenth century bc in Egypt. A pharmacopoeia that classified more than 700 drugs was written to assist in the care and management of disease (Ellis and Hartley, 2008). As in the case of Shiphrah and Puah, the midwives who saved the baby Moses, nurses were used by kings and other aristocrats to deliver babies and care for the young, older adults, and those who were sick.

Following these improvements, the Frontier Nursing Service (FNS) was established in 1925 by Mary Breckenridge of Kentucky.

Born into a wealthy family, Breckenridge learned the value of providing care to others from her grandmother. Breckenridge began her career in 1415 New York's St. Luke's Hospital School of Nursing. After serving as a nurse during WWI, she returned to Columbia University to learn more about community health nursing. Armed with her new knowledge and a passion to assist disadvantaged women and children, Breckenridge returned to Kentucky and the rural Appalachian Mountains (Oermann, 1997; Stanhope and Lancaster, 2008). Breckenridge believed that the rural mountain area of Kentucky, cut off from many modern conveniences, was an excellent place to prove the value of community health nursing. She established the FNS in a five-room cabin in Hyden, Kentucky. After overcoming serious obstacles, such as no water supply or sewage disposal, six other nursing outposts were constructed in the rural mountains from 1927 to 1930. The FNS based its hospital in Hyden and eventually attracted physicians and nurses to provide medical, dental, surgical, nursing, and midwifery services to the rural poor. Financial support for the FNS ranged from fees for labor and supplies to funds raised through annual family dues to donations and fundraising efforts. Nurses working for the FNS traveled a 700-square mile area, often on horseback, to provide services to approximately 10,000 patients (Oermann, 1997). Breckenridge established an important health care service for rural Kentucky communities. Equally important was her documentation of the results of community health nursing in rural communities. Breckenridge followed the advice of a consulting physician and collected mortality data on the communities before nursing services actually were started. The results were startling; mortality was significantly reduced, and the need for the nursing services was clearly documented. Breckenridge proved that even in appalling environmental conditions without heat, electricity, or running water, nursing services could make a substantial positive impact on the health of the community (Stanhope and Lancaster, 2008). The FNS is still in operation today and provides vital service to the rural communities of Kentucky.

Exposure to hazardous materials became a major issue of concern for not only health care workers but also the general public

Chemical and radioactive substances that created dangerous exposure and health risks were increasingly used in the workplace. Employers were held legally accountable for informing their employees of the actual or potential hazards and for reducing their exposure risk through training and the use of protective equipment. The hazardous materials issue was especially important in nursing and medicine, particularly with regard to exposure to carcinogenic chemicals used in drug therapy and in environmental infection control.

Florence Nightingale (1820 to 1910)

Considered the founder of organized, professional nursing. She is best known for her contributions to the reforms in the British Army Medical Corps, improved sanitation in India, improved public health in Great Britain, use of statistics to document health outcomes, and the development of organized training for nurses.

India

Dating from 3000 to 1500 bc, the earliest cultures of India were Hindu. The sacred book of Brahmanism (also known as Hinduism), the Vedas, was used to guide health care practices. The Vedas, considered by some to be the oldest written material, emphasized hygiene and prevention of sickness and described major and minor surgeries. The Indian practice of surgery was very well developed. The importance of prenatal care to mother and infant was also well understood. Public hospitals were constructed from 274 to 236 bc and were staffed by male nurses with qualifications and duties similar to those of the twentieth-century practical nurse. In rare instances, older women were allowed to assume a nursing role outside the home (Ellis and Hartley, 2008).

The Civil War Period

During the United States Civil War, or the War Between the States (1861 to 1865), health care conditions in the United States were similar to those encountered by Nightingale and Seacole. Numerous epidemics plagued the country, including syphilis, gonorrhea, malaria, smallpox, and typhoid (Nelson, 2001; Oermann, 1997). The Civil War was initiated by the attack on Fort Sumter, South Carolina, April 17, 1861. At this time, there were no nurses formally trained to care for the sick. However, thousands of men and women from the South and North volunteered to care for the wounded. Hospitals were set up in the field, and transports were put in place to carry the wounded to the hospitals (Carnegie, 1995). Secretary of War Simon Cameron appointed a schoolteacher named Dorothea Dix to organize military hospitals and provide medical supplies to the Union Army soldiers. Dix received no official status and no salary for this position. Women providing nursing care during the Civil War worked under very primitive conditions. Maintaining sanitary conditions was an overwhelming challenge and often not possible. Greater than 6 million patients were admitted to hospitals. There were approximately one-half million surgical cases performed. Unfortunately there were only about 2000 individuals who served as nurses, far less than the number needed to provide adequate care (Fitzpatrick, 1997; Kalisch and Kalisch, 1995). According to records kept at three hospitals, 181 men and women African-American nurses served between July 16, 1863, and June 14, 1864. White nurses were paid $12 per month; African-American nurses received $10 per month (Carnegie, 1995). Three African-American nurses made particularly important contributions to nursing efforts during the Civil War: Harriet Tubman cared for the sick as a nurse in the Sea Islands off the coast of South Carolina and was later known as the "conductor of the underground railroad." It is also reported that she was the first woman to lead American troops into battle (Carnegie, 1995). Sojourner Truth, known for her abolitionist and nursing efforts, was an 1112 advocate of clean and sanitary conditions for patients. She insisted that these conditions were needed for patients to heal. Susie King Taylor, although hired to work in the laundry, served as a nurse because of the growing number of wounded who needed care. Having learned to read and write, which was against the law for African-Americans at the time, she also taught many of her comrades in Company E to read and write (Carnegie, 1995).Many other volunteer nurses made important contributions during the Civil War: Clara Barton served on the front line during the Civil War and operated a war relief program to provide supplies to the battlefields and hospitals. Barton also set up a postwar service to find missing soldiers and is credited with founding the American Red Cross (Nelson, 2001; Oermann, 1997). Louisa May Alcott, who served as a nurse for 6 weeks until stopped by ill health, authored detailed accounts of the experiences encountered by nurses during the war for a newspaper publication titled Hospital Sketches (Kalisch and Kalisch, 1995; 2003). When the Civil War ended, the number of nurse training schools increased. The war had proven the need for more nurses to be formerly trained. These early nursing programs offered little or no classroom education, and on-the-job training occurred in the hospital wards. The students learned routine patient care duties, worked long hours 6 days a week, and were used as supplemental hospital staff. After graduation most of the nurses practiced as private duty nurses or hospital staff (Lindeman and McAthie, 1990). The first nursing textbook, titled A Manual of Nursing, was published in 1876 and was used by the New York Training School for Nurses at Bellevue Hospital (Kalisch and Kalisch, 1995). During the 1890s, the nationwide establishment of African-American hospitals and nursing schools gained momentum as African-American musicians, educators, and community leaders became alarmed at the high rates of African-American morbidity and mortality. Because of segregation and discrimination, African-Americans had to establish their own health care institutions to provide African-American patients with access to quality health care and to provide African-American men and women with opportunities to enter the nursing profession. In 1886 John D. Rockefeller funded the establishment of the first school of nursing for African-American women at the Atlanta Baptist Seminary—now known as Spelman College (Jones, 2004; Salzman, Smith, and West, 1996). 1900 to World War I In the 1900s states began to require nurses to become registered before entering practice. By 1910 most states had upgraded education requirements to high school, upgraded training, and required registration before practice (Deloughery, 1

World War I and the 1920s

During the early 1900s the world was rapidly changing and moving toward global conflict. Germany was arming, and the rest of Europe was trying to ignore the threat. "Prosperous" was the word used to describe the U.S. economy. Women were granted the right to vote and were moving into the workforce on a regular basis. Advancements in medical care and public health were being made. The primary site for medical care moved from the home to the hospital, and surgical and diagnostic techniques were improved. Pneumonia management was the focus of scientific study. Insulin was discovered in 1922, and in 1928 Alexander Fleming discovered the precursor of penicillin, which would eventually be used to successfully treat patients with pneumonia and other infections (Kalisch and Kalisch, 1995) (Box 1-2). Environmental conditions improved, and the serious epidemics of the previous century became nonexistent. Lillian Wald, in The House on Henry Street, linked poor environmental and social conditions to prevalent illnesses and poverty and used this information to lead the fight for better sanitation and housing conditions (Nies and McEwen, 2007). With the outbreak of World War I in 1914, nurses were desperately needed to care for the soldiers who were injured or who suffered from the many illnesses that were a result of trench warfare (Nies and McEwen, 2007). The war offered nurses a chance to advance into new fields of specialization. For example, nurse anesthetists made their first appearance as part of the surgical teams at the front lines. More than 20,000 U.S.-trained nurses served in WWI (Oermann, 1997). Because many nurses volunteered to provide services during the war, the community health nursing movement in the United States stalled. However, the American Red Cross, founded by Clara Barton in 1882, assisted in efforts to continue public health nursing. The Red Cross nurses originally focused on the rural communities that were not able to access health care services. As the war continued, however, the Red Cross nurses also moved into urban areas to provide health care services (Chitty and Black, 2007).

Nursing in the 1960s

Federal legislation enacted during the 1960s had a major and lasting effect on nursing and health care. The Community Mental Health Centers Act of 1963 provided funds for the construction of community outpatient mental health centers; opportunities for mental health nursing were expanded when funds to staff these centers were appropriated in 1965 with the passage of the Medicare and Medicaid acts (Boschma, 2003). Medicaid, Title XIX of the Social Security Act, was enacted and replaced all programs previously instituted for medical assistance. The purpose of the Medicaid program, which was jointly sponsored and financed with matching funds from federal and state governments, was to serve as medical insurance for those families, primarily women and children, with an income at or below the federal poverty level. Medicaid quickly became "the largest public assistance program in the nation, covering about 9.7% of the population, including more than 15% of all children," (Baer, D'Antonio, and Rinker, 2002).

FLORENCE NIGHTINGALE

Florence Nightingale was born in Florence, Italy, on May 12, 1820. The Nightingale family was wealthy, well traveled, and well educated. Nightingale was a highly intelligent, talented, and attractive woman. From an early age she demonstrated a deep concern for the poor and suffering. At the age of 25 she became interested in training as a nurse. However, her family was strongly opposed to this choice and preferred that she marry and take her place in society (Joel, 2006). In 1851 her parents finally permitted her to pursue training as a nurse. Nightingale attended a 3-month nursing training program at the Institution of Deaconesses at Kaiserswerth, Germany. In 1854 she began training nurses at the Harley Street Nursing Home and served as superintendent of nurses at King's College Hospital in London (Small, 2002). The outbreak of the Crimean War marked a turning point in Nightingale's career. In October 1854, Sidney Herbert, British Secretary of War and an old friend of the Nightingale family, wrote to Nightingale and asked her to lead a group of nurses to the Crimea to work at one of the military hospitals under government authority and expense. Nightingale accepted his offer and assembled 38 nurses who were sisters and nuns from various Catholic and Anglican orders (Joel, 2006; Small, 2002). Nightingale and her team were assigned to the Barracks Hospital at Scutari. The Barracks Hospital actually was a dilapidated, barnlike building that had been formerly used as artillery barracks. Thousands of cholera victims and hundreds of battle casualties were taken to Scutari. To get to the hospital from the front lines, the wounded and ill soldiers were put aboard hospital ships to cross the long Black Sea (Small, 2002). When Nightingale arrived at the Barracks Hospital, she found deplorable conditions. Between 3000 and 4000 sick and wounded men were packed into the hospital, which was originally designed to accommodate 1700 patients. There were no beds, blankets, food, or medicine. Many of the wounded soldiers had been placed on the floor, where lice, maggots, vermin, rodents, and blood covered their bodies. There were no candles or lanterns. All medical care had to be rendered during the light of day (Small, 2002). Despite the distressing conditions at the Barracks Hospital, the army physicians and surgeons at first refused Nightingale's assistance. However, within a week, faced with scurvy, starvation, dysentery, and the eruption of more fighting, the physicians, in desperation, called her to help. Nightingale immediately purchased medical supplies, food, linen, and hospital equipment, using her own money and that of the Times Relief Fund. Within 10 days she had set up 910 a kitchen for special diets and had rented a house that she converted into a laundry (Gill 2004; Small, 2002). The wives of soldiers were hired to manage and operate the laundry service. She assigned soldiers to make repairs and clean up the building. Just weeks later she initiated social services, reading classes, and even coffeehouses, where soldiers could enjoy music and recreation (Small, 2002). Nightingale worked long, hard hours to care for these soldiers. She spent up to 20 hours each day caring for wounds, comforting soldiers, assisting in surgery, directing staff, and keeping records. Nightingale introduced principles of asepsis and infection control, a system for transcribing physicians' orders, and a procedure to maintain patient records. By the end of the Crimean War, Nightingale had trained as many as 125 nurses to care for the wounded and ill soldiers (Small, 2002). Nightingale is credited with using public health principles and statistical methods to advocate for improved health conditions for British soldiers. Through carefully recorded statistics, Nightingale was able to document that the soldiers' death rate decreased from 42% to 2% as a result of health care reforms that emphasized sanitary conditions. Because of her remarkable work in using statistics to demonstrate cause and effect and improve the health of British soldiers, Nightingale is recognized for her contributions to nursing research (Nies and McEwen, 2007). Nightingale also demonstrated the power of political activism to effect health care reform by writing letters of criticism accompanied by constructive recommendations to British army leaders. Nightingale's ability to overthrow the British army management method that had allowed the deplorable conditions to exist in the army hospitals was considered one of her greatest achievements (Dossey et al, 2005; Gill, 2004; Nies and McEwen, 2007). In 1855 after visiting the front lines and hospitals in Balaclava, Nightingale contracted "Crimean fever" and was taken to the Castle Hospital. There she received intensive care from the physicians and nurses she trained. She remained in poor condition for several weeks. Soldiers wept when they heard of her illness and near death. She eventually recovered, but the illness had taken a heavy toll on her overall health (Luddy et al, 2004). In 1860 Nightingale established the first nursing school in England. By 1873 graduates of Nightingale's nurse training program in England migrated to the United States, where they became supervisors in the first of the hospital-based (diploma) nursing schools: Massachusetts General Hospital in Boston, Bellevue Hospital in New York, and the New Haven Hospital in Connecticut. Florence Nightingale's work, from the Crimean War to the establishment of formal nursing education programs, was a catapult for the reorganization and advancement of professional nursing. Until her death in August 1910, Nightingale demonstrated the powerful effect that well-educated, creative, skilled, and competent individuals have in the provision of health care. She is honored as the founder of professional nursing (Small, 2002). Nightingale had the means to support her work and the stamina to drive forward in her belief concerning health care. Her theory of environmental cleanliness is still applicable today, even though Louis Pasteur's germ theory was not widely known and was very controversial at the time.

THE RENAISSANCE AND THE REFORMATION PERIOD

Following the Middle Ages came the Renaissance and the Reformation, also known as the rebirth of Europe (the fourteenth through the sixteenth centuries ad). Major advancements were made in pharmacology, chemistry, and medical knowledge, including anatomy, physiology, and surgery. During the Renaissance, new emphasis was given to medical education, but nursing education was practically nonexistent. The Reformation was a religious movement that resulted in a dissention between Roman Catholics and Protestants. During this period, religious facilities that provided health care closed. Women were encouraged toward charitable services, but their main duties included bearing and caring for children in their homes. Furthermore, hospital work was no longer appealing to women of high economic status, and the individuals who worked as nurses in hospitals were often female prisoners, prostitutes, and drunks. Nursing was no longer the respected profession it had once been. This period is referred to as the "Dark Ages" of nursing (Ellis and Hartley, 2008). During the sixteenth and seventeenth centuries, famine, plague, filth, and horrible crimes ravaged Europe. King Henry VII eliminated the organized monastic relief programs that aided the orphans, poor, and other displaced people. It became common to encounter homeless men, women, and children begging in the streets. Beggars were beaten, branded, and chained to the galleys of boats as punishment for their disgraceful behavior (Ellis and Hartley, 2004). Out of great concern for social welfare, several nursing groups, such as the Order of the Visitation of St. Mary, St. Vincent de Paul, and the Sisters of Charity, were organized to give time, service, and money to the poor and sick. The Sisters of Charity recruited young women for training in nursing, developed educational programs, and cared for abandoned children. 89 In 1640 St. Vincent de Paul established the Hospital for the Foundling to care for the many orphaned and abandoned children (Ellis and Hartley, 2008).

Palestine

From 1400 to 1200 bc, the Hebrews migrated from the Arabian Desert and gradually settled in Palestine, where they became an agricultural society. Under the leadership of Moses, the Hebrews developed a system of laws called the Mosaic Code. This code, one of the first organized methods of disease control and prevention, contained public health laws that dictated personal, family, and public hygiene. For instance, laws were written to prohibit the eating of animals that were dead longer than 3 days and to isolate individuals who were thought to have communicable diseases. Hebrew priests took on the role of health inspectors (Ellis and Hartley, 2004).

Greece

From 1500 to 100 bc, Greek philosophers sought to understand man and his relationship with the gods, nature, and other men. They believed that the gods and goddesses of Greek mythology controlled health and illness. Temples built to honor Aesculapius, the god of medicine, were designated to care for the sick. Aesculapius carried a staff that was intertwined with serpents or snakes, representing wisdom and immortality. This staff is believed to be the model of today's medical caduceus. Hippocrates (460 to 362 bc), considered the "Father of Medicine," paved the way in establishing scientific knowledge in medicine. Hippocrates was the first to attribute disease to natural causes rather than supernatural causes and curses of the gods. Hippocrates' teachings also emphasized the patient-centered approach and use of the scientific method for solving problems (Ellis and Hartley, 2004).

Also in the late 1980s several nursing scholars suggested that nursing research be firmly focused on the substantive information required to guide practice, rather than on philosophic and methodologic dilemmas of scientific inquiry.

In 1985 the creation of the National Center for Nursing Research at the National Institutes of Health brought with it an increase in federal resources for nursing research and research training (Baer et al, 2002; Hinshaw, 1999).

The 1990s began with alarm over the state of the U.S. economy. Government statisticians reported an alarming increase in the national debt complicated by slow economic growth

In the early 1990s, average household incomes were stagnating. More women with families entered the workforce to afford the increasing cost of living. More nurses selected jobs in which they could work more hours in fewer days for more money, sometimes sacrificing the fringe benefits, allowing them to work a second job or earn higher pay through shift differential for working evening and night shifts. Creative shifts, such as the 10-hour day, 4-day work week or the 12-hour day, 3-day work week became commonplace in health care facilities. Just as in the 1980s, the cost of health care continued to increase with the technologic advancements in medical care. Men were considered a minority in nursing, and salaries were thought to be on the increase as a result of male presence in the profession (O'Lynn and Tranbarger, 2006).

In 1918 the Vassar Camp School for Nurses was established

Its purpose was to provide an intensive 2-year nurses' training program for college graduates. Graduates of the program were given an army reserve commission and would be activated during times of war to meet increased nursing needs. Sponsored by the American Red Cross and the Council of National Defense, the school graduated 435 nurses. The Vassar Camp School for Nurses was a short-lived enterprise. When peace was declared in 1919, the program was permanently disbanded (Snodgrass, 2004; Stanhope and Lancaster, 2008).

As a result of Medicare reimbursement, hospital-bed occupancy increased, which led to increased numbers of nurses needed to staff hospitals.

Nursing embraced the hospital setting as the usual practice area and moved away from the community as the preferred practice site. Nursing schools also followed the trend by reducing the number of curriculum hours devoted to community health and concentrated their efforts on hospital-based nursing (Stanhope and Lancaster, 2008).

There also were growing concerns in the 1990s about the health of the nation, which prompted the Healthy People 2000 initiative

Many diseases associated with preventable causes characterized mortality in the United States. In 1990 more than 2 million U.S. residents died from diseases, such as heart disease, cancer, cerebral vascular disease, accidents, chronic obstructive pulmonary disease, liver cirrhosis, tuberculosis, and human immunodeficiency virus infection. The inner city became a concern of disparities in these diseases with issues related to access and quality of care (Karels, 2005). Factors contributing to these common diseases state related to lifestyle patterns, behaviors, and habits (modifiable risk factors). More youth were at risk because of behavior such as smoking cigarettes, using abusive drug substances, eating poorly balanced diets, failing to exercise, having sex with multiple partners, and being subjected to acts of violence. Healthy People 2000: National Health Promotion and Disease Prevention Objectives was published in 1991 by the U.S. Department of Health and Human Services as a nationwide effort to help states, cities, and communities identify health promotion and disease prevention strategies to address these health risk problems.

MARY SEACOLE

Mary Seacole was a Jamaican nurse who learned the art of caring and healing from her mother. In her native land of Jamaica, British West Indies, she was nicknamed "Doctress" because of her administration of care to the sick in a lodging house in Kingston (Carnegie, 1995). Seacole learned of the Crimean War and wrote to the British government requesting to join 1011 Nightingale's group of nurses. However, she was denied the right to join because she was black. She was confused about this denial because many of the British soldiers had lived in Jamaica, where she had already provided health care to them. Seacole had previously served as a nurse in Cuba and Panama during the yellow fever and cholera epidemics. She had also conducted forensic studies on an infant who died of cholera in Panama. She felt that her experience would be valuable in treating disease in the Crimean War, and she sailed to England at her own expense. She provided a letter of introduction to Nightingale, which was blocked because Seacole was black, even though she had been trained by British army physicians (Carnegie, 1995). After several efforts to join Nightingale's group failed, Seacole, who was not a woman of wealth, purchased her own supplies and traveled more than 3000 miles to the Crimea, where she built and opened a lodging house. On the bottom floor of the house was a restaurant, and on the top floor an area was arranged like a hospital to nurse sick soldiers (Carnegie, 1995). When Seacole finally met Nightingale, the response was still the same: "no vacancies" (Carnegie, 1995). However, being denied enlistment did not deter Seacole; she remained faithful and nursed the sick throughout the Crimean War. Her efforts did not go unnoticed by the English people. Long after the war was over, the British government finally honored Seacole with a medal in recognition of her efforts and the services she provided to the sick and injured soldiers.

Despite the high cost of health care, medicine prospered

Medical care advanced in areas such as organ transplantation, resuscitation and support of premature infants, and critical care techniques. Physician specialization and advances in medical technology flourished. Medical specialties, such as nephrology, cardiology, endocrinology, orthopedics, neurosurgery, cardiovascular surgery, and advanced practices for obstetrics all led to improved health care services and costs in the hospital setting. The advanced technology also led to the development of outpatient surgery units. Outpatient surgery services blossomed and provided a quick and efficient site for surgery that did not require extended hospital stays. Costs were greatly reduced because of fewer staff members needed for coverage, fewer supplies, and reduced facility costs. Nurses were interested in employment opportunities in outpatient facilities because they afforded a chance to work only during the day with no weekend assignments.

Runaway health care costs became a national issue in the 1980s.

Medicare was still reimbursing for any and all hospital services provided to recipients. From 1966 to 1981, the federal contribution to hospital care rose from 13% to 41% (Baer et al, 2002). In 1983 in an attempt to restrain hospital costs, Congress passed the Diagnosis-Related Group system for reimbursement, better known as the DRG system. Before 1983 Medicare payments were made to the hospital after the patient received services. Although there were restrictions, the entire bill generally was paid without question. DRGs were implemented to provide prospective payment for hospital services based on the patient's admitting diagnosis and thereby to reduce the overall cost to Medicare. Hospitals now were to be reimbursed one amount based on the patient's diagnosis, not on hospital charges. The system was developed by physicians at the Yale-New Haven Hospital and addressed approximately 468 diagnoses classified according to length of stay and cost of procedures associated with the diagnosis (Nies and McEwen, 2007).

In June 1993, the National Center for Nursing Research was renamed the National Institute of Nursing Research.

Moving nursing research into the National Institutes of Health enhanced the interprofessional possibilities for collaborative investigation. As a result, nursing research grew rapidly during the 1990s. Multiple research programs focused on important health issues, such as health promotion across the life span. Nursing research began to inform health care policy through federal commissions and agency programs

PREHISTORIC PERIOD

Nursing in the prehistoric period was delineated by health practices that were strongly guided by beliefs of magic, religion, and superstition. Individuals who were ill were considered to be cursed by evil spirits and evil gods that entered the human body and caused suffering and death if not cast out. These beliefs dictated the behavior of primitive people, who sought to scare away the evil gods and spirits. Members of tribes participated in rituals, wore masks, and engaged in demonstrative dances to rid the sick of demonic possession of the body. Sacrifices and offerings, sometimes including human sacrifices, were made to rid the body of evil gods, demons, and spirits. Many tribes used special herbs, roots, and vegetables to cast out the "curse" of illness.

In 1974 the ANA conducted research in the area of ethnic minorities and submitted a proposal to the National Institute of Mental Health to fund a project to permit minority nurses—African-Americans, Hispanics, Asians, and American Indians—to earn PhDs.

Of the graduates of the project, the vast majority serve on faculties of universities and are conducting research on factors in mental health and illness related to ethnicity and cross-cultural conflict, thereby fulfilling their commitment to advance the cause of quality health care for people of all ethnicities.Despite past laxity, the ANA House of Delegates at its 1972 convention did pass an affirmative action resolution calling for a task force to develop and implement a program to correct inequities. The house also provided for the position of an ombudsman to evaluate involvement of minorities in leadership roles within the organization and to treat complaints by applicants for membership or by members of the association who had been discriminated against because of nationality, race, creed, lifestyle, color, age, or sex. It was also in the 1970s that the ANA elected its first African-American president, Barbara Nichols, who served two terms. Within the structure of many professional organizations is a unit referred to as an academy, which is composed of a cadre of scholars who deal with issues that concern the profession and take positions in the name of the academy. The American Academy of Nursing (AAN) was created by the ANA board in 1973. An elected group of highly accomplished leaders across all sectors of nursing (education, research, and practice), it uses the credential FAAN (Fellow, American Academy of Nursing). Through the application of visionary leadership, the intent of the AAN is to transform health care policy through nursing knowledge to optimize the well-being of the American people. At its convention in Atlantic City in 1976, the ANA launched its Hall of Fame to pay tribute to those nurses who had not only paved the way for others to follow but also made outstanding contributions to the profession.

Nursing in the Twenty-First Century

Professional nurses in the twenty-first century are faced with many challenges within the dynamic state of health care. In addition to the issues of access, cost, quality, safety, and accountability in health care, nurses today are challenged by an aging population, a serious nursing shortage, generational differences in an aging workforce with poor prospects for replacements, high acuity and short staffing, conflict in the workplace, expanding technology, complex consumer health values, and an increasingly intercultural society. Nurses have identified numerous areas of concern, including insufficient staffing, inadequate salaries, effects of stress and overwork, lack of participation in decision making, and dissatisfaction with the quality of their own nursing care. Changing duties, responsibilities, and conflicts amid nursing shortages and public concern over patient safety and quality of care characterize present-day practice. These changes require professional nurses to have core competency in critical thinking, communication, interprofessional collaboration, assessment, leadership, and technical skills, in addition to knowledge of health promotion and disease prevention, information technology, health systems, and public policy. 22 23 According to AACN's report on 2008-2009 Enrollment in Baccalaureate and Graduate Programs in Nursing, U.S. nursing schools turned away 49,948 qualified applicants due to insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints. Like the overall nursing workforce, mean age of faculty has increased steadily from 49.7 years in 1993 to 54 in 2008 (AACN, 2009). Public funding to schools of nursing needs to be increased to attract and retain nursing faculty. In support of the nursing profession, the U.S. Congress adopted the Nurse Reinvestment Act to provide funds for nursing education, recruitment, and retention programs. President George W. Bush signed the bill into law in August 2002. In May 2003 the IOM released recommended partnerships of academic institutions, local and state public health departments, community health agencies, and schools of public health to establish training for medical and nursing school curricula. The future of public health in our nation depends on a competent, well-trained public health workforce. A well-trained workforce is in the best interest of all those concerned with maintaining a healthy society (Institute of Medicine [IOM], 2003). Nursing is the nation's largest health care profession with more than 2.9 million RNs nationwide. Nurses make up the largest single component of hospital staff, are the primary providers of hospital patient care, and deliver most of the nation's long-term care. According to the U.S. Bureau of Labor Statistics, registered nursing is the occupation with the largest job growth from 2002 to 2012 (Hecker, 2004). Nursing students account for more than half (52%) of all health professions students in the United States. The nursing profession has risen to the challenges of the twenty-first century by uniting efforts to shape health care and the profession. Numerous coalitions have been formed to address the critical nursing shortage; increased political liaisons have influenced health policy; and involvement in evidence-based practice is more prevalent than ever and continues to improve health outcomes for individuals, groups, communities, and the nation (Connelly, 2004).

The AIDS epidemic radically changed the process for infection control among health care workers in health care institutions across the nation.

Recapping needles, wearing latex gloves, and using isolation precautions were issues that triggered much dialogue and debate among health care workers. Health care workers were mandated to use preventive measures in the form of Universal Precautions; all contact with blood and body fluids from all patients was considered potentially infectious.

Another important amendment to the Social Security Act was Title XVIII, or Medicare, passed in 1965.

The Medicare program provides hospital insurance, part A, and medical insurance, part B, to all people ages 65 and older who are eligible to receive social security benefits; people with total, permanent disabilities; and people with end-stage renal disease. As a result of Medicare reimbursement, many hospitals began catering to physicians who treated Medicare patients. Medicare patients were attractive to the hospitals because all hospital charges, regardless of amount or appropriateness of services, were reimbursed through the Medicare program (Chitty and Black, 2007).

THE MIDDLE AGES

The Middle Ages (476 bc to 1450 ad) followed the demise of the Roman Empire (Walton et al, 1994). Women used herbs and new methods of healing, whereas men continued to use purging, leeching, and mercury. This period also saw the Roman Catholic Church become a central figure in the organization and management of health care. Most of the changes in 78 health care were based on the Christian concepts of charity and the sanctity of human life. Wives of emperors and other women considered noble became nurses. These women devoted themselves to caring for the sick, often carrying a basket of food and medicine as they journeyed from house to house (Bahr and Johnson, 1997). Widows and unmarried women became nuns and deaconesses. Two of these deaconesses, Dorcas and Phoebe, are mentioned in the Bible as outstanding for the care they provided to the sick (Freedman, 1995). During the Middle Ages, physicians spent most of their time translating medical essays; they actually provided little medical care. Poorly trained barbers, who lacked any formal medical education, performed surgery and medical treatments that were considered "bloody" or "messy." Nurses also provided some medical care, although in most hospitals and monasteries, female nurses who were not midwives were forbidden to witness childbirth, help with gynecologic examinations, or even diaper male infants (Kalisch and Kalisch, 1986). In addition these nurses were not permitted to have contact with male patients, administer enemas, or care for a man with a venereal disease. Female nurse midwives did, however, provide the bulk of obstetric care within the community (Ellis and Hartley, 2008). During the Crusades, which lasted for almost 200 years (from 1096 to 1291), military nursing orders, known as Templars and Hospitalers, were founded. Monks and Christian knights provided nursing care and defended the hospitals during battle, wearing a suit of armor under their religious habits. The habits were distinguished by the Maltese cross to identify the monks and knights as Christian warriors. The same cross was used years later on a badge designed for the first school of nursing and became a forerunner for the design of nursing pins (Ellis and Hartley, 2004).

The end of WWII and the early 1950s marked the beginning of significant federal intervention in health care.

The Nurse Training Act of 1943 was the first instance of federal funding being used to support nurse training. The passage of the Hill-Burton Act, or the Hospital Survey and Construction Act of 1946, marked the largest commitment of federal dollars to health care in the country's history. The purpose of the act was to provide funding to construct hospitals and to assist states in planning for other health care facilities based on the needs of 1617 the communities. Nearly 40% of the hospitals constructed in the late 1940s and the early 1950s were built with Hill-Burton funds. The hospital construction boom created by the Hill-Burton Act led to an increased demand for professional nurses to provide care in hospitals (Chitty and Black, 2007).

Rome

The Roman Empire (27 bc to 476 ad), a military dictatorship, adapted medical practices from the countries they conquered and the physicians they enslaved. The first military hospital in Europe was established in Rome. The physicians were enslaved and forced to provide details about their medical practice. Both male and female attendants assisted in the care of the sick. Galen was a famous Greek physician who worked in Rome and made important contributions to the practice of medicine by expanding his knowledge in anatomy, physiology, pathology, and medical therapeutics (Walton et al, 1994).

The Great Depression (1930 to 1940)

The U.S. economy prospered during WWI and well into the 1920s. However, after the stock market crash in October 1929, economic prosperity quickly dissipated. Millions of men and women became unemployed. Before the depression many people had private-duty nurses. However, during the depression, many nurses found themselves unemployed because most families could no longer afford private-duty nurses. Franklin D. Roosevelt, elected president of the United States in 1932, faced a country in shambles. He responded with several innovative and necessary interventions and ushered in the first major social legislation that had been enacted in U.S. history. Titled the "New Deal," the legislation had several social components that affected the provision of medical care and other services for indigent people across the country (Karger and Stoesz, 2005).

World War II (1940 to 1945)

The United States officially entered World War II after the bombing of Pearl Harbor in December 1941. At that time the nursing divisions of all of the military branches had inadequate numbers of nurses. Congress passed legislation to provide needed funds to expand nursing education. A committee of six national nursing organizations, called the National Nursing Council, received a million dollars to accomplish the needed expansion. The U.S. Public Health Service became the administrator of the funds, which further strengthened the tie between the U.S. Public Health Service and nursing (Sarnecky, 2001; Stanhope and Lancaster, 2008). The war was considered a global conflict, and nursing became an essential part of the military advance. Nurses were required to function under combat conditions and had to adapt nursing care to meet the challenges of different climates, facilities, and supplies. As a result of their service during WWII, nurses finally were recognized as an integral part of the military and attained the ranks of officers in the army and navy. Colonel Julie O. Flikke was the first army nurse to be promoted to colonel in the U.S. Army and served as Superintendent of the Army Nurse Corps from 1937 to 1942 (Deloughery, 1998; Robinson and Perry, 2001).

Nursing enrollments dropped drastically in the late 1980s

This drop in enrollment occurred as the complexity of health care was rapidly increasing and more nurses were assuming expanded roles. As a result of these trends, a serious national shortage of nurses occurred across all settings

THE COLONIAL AMERICAN PERIOD

The first hospital and the first medical school in North America were founded in Mexico—the Hospital of the Immaculate Conception in Mexico City and the medical school at the University of Mexico. During this time in the American colonies, individuals with infectious diseases were isolated in almshouses or "pesthouses" (Ellis and Hartley, 2008). Procedures, such as purgatives and bleeding, were widely used, leading to shortened life expectancy. Plagues, such as yellow fever and smallpox, caused thousands of deaths. Benjamin Franklin, who was outspoken regarding the care of the sick, insisted that a hospital be built in the colonies. He believed that the community should be responsible for the management and treatment of those who were ill. Through his efforts, the first hospital, called the Pennsylvania Hospital, was built in the United States in Philadelphia in 1751 (Ellis and Hartley, 2008).

Post-World War II Period (1945 to 1950)

The period after WWII was a time of prosperity for the average American. The GI Bill enabled returning veterans to complete their interrupted education. The unemployment rate dropped to an all-time low in the United States. In an effort to provide more areas of employment for the returning men, the government mounted a massive campaign to encourage women to return to the more traditional roles of wife and mother. Consequently, numerous women in all professions, including nursing, chose to return to marriage and childrearing rather than continue employment outside the home. After WWII communism demonstrated its strength more than ever as the Soviet Union began invading and taking over Eastern European countries. With support from China, the North Koreans made a grab for South Korea, resulting in the Korean War. Again, nurses volunteered for the armed services to provide care to patients near the battlefields in Korea. This time they worked in mobile army surgical hospitals, better known as MASH units, where medical and surgical techniques were further refined. The two decades after WWII saw the emergence of nursing as a true profession. Minimal national standards for nursing education were established by the National Nursing Accrediting Service. In 1945 state boards of nurse examiners in 25 states adopted the state board test pool. By 1950 all state boards were participating in the test pool; they continue to do so today. Nursing continued to improve the quality and quantity of educational programs as the number of nursing baccalaureate programs grew and associate degree programs developed in community or junior colleges (Kalisch and Kalisch, 1995; Robinson and Perry, 2001) (Box 1-3).

China

The teachings of the Chinese scholar Confucius (551 to 479 bc) had a powerful effect on the customs and practices of the people of ancient China. Confucius taught a moral philosophy that addressed one's obligation to society. Several hundred years after his death, Confucius' philosophy became the basis for Chinese education and government. Central to his teachings were service to the community and the value of the family as a unit. The early Chinese also placed great value on solving life's problems. Their belief about health and illness was based on the yin and yang philosophy. The yin represented the feminine forces, which were considered negative and passive. The yang represented the masculine forces, which were positive and active. The Chinese believed that an imbalance between these two forces would result in illness, whereas balance between the yin and yang represented good health (Ellis and Hartley, 2008). The ancient Chinese used a variety of treatments believed to promote health and harmony, including acupuncture. Acupuncture involves insertion of hot and cold needles into the skin and underlying tissues to manage or cure conditions (such as pain, stroke, or breathing difficulty) and ultimately to affect the balance of yin and yang. Hydrotherapy, massage, and exercise were used as preventive health measures (Giger and Davidhizar, 2004). The Chinese also used drug therapy to manage disease conditions; they recorded more than 1000 drugs derived from animals, vegetables, and minerals (Walton, Barondess, and Locke, 1994). Many of the drugs used by the Chinese in ancient times, such as ephedrine, continue to be used today (Ellis and Hartley, 2004).

Nursing in the 1980s

The types of patients needing health care changed in the 1980s. Homelessness became a common problem in large cities. Unstable economic developments contributed to an increase in indigent populations (Baer et al, 2002). Acquired immunodeficiency syndrome (AIDS) emerged as a frightening, fatal epidemic.

Nursing in the 1970s

The women's movement of the 1970s greatly influenced nursing. Nurses began to focus not only on providing quality care to patients but also on enhancing the economic benefits of the profession. Hospitals were receiving significant reimbursements for patient care; however, nurses' salaries did not reflect an adequate percentage of that reimbursement. Health care costs soared. This increase in health care costs built the framework for mandated changes in reimbursement. Nursing practice and the educational focus remained in the hospital setting. During this time nurses played a major role in providing health care to communities and were instrumental in developing hospice programs, birthing centers, and daycare centers for older adults (Buhler-Wilkerson, 2001). Although basic educational programs for nurse practitioners expanded during the 1970s and master's-level preparation was developed as the requirement for graduation and practice, certification was also required to practice as a nurse practitioner. Before this time, only certification was required. State nursing practice acts were amended to provide for monitoring and licensing advanced practice nurses. Men also began to increase in numbers in this female-dominated profession (O'Lynn and Tranbarger, 2006).

In the 1990s, a partnership was forged between mandatory state licensure authorities, which set practice standards at the level of entering associate-degree graduates, and national, nongovernmental bodies that certify graduate-prepared specialists.

These national certifying agencies were intensely engaged in improving methods for determining the continual competence of certified nurse practitioners within the swift current of health care change. The consumer's voice in the partnership was heard via collaboration with advocacy organizations and the appointment of more public members to licensing, certifying, and accreditation boards. Voluntary credentialing bodies recognized that if they were to serve effectively, they had to engage in active public information campaigns to inform consumers about their health care choices (Buhler-Wilkerson, 2001).

Lillian Wald

a pioneer in public health nursing, is best known for the development and establishment of a viable practice for public health nurses in the twentieth century. The main location for this practice was the Henry Street Settlement House, located in the Lower East Side of New York City. Its purpose was to provide well-baby care, health education, disease prevention, and treatment of patients with minor illnesses. Nursing practice based at the Henry Street Settlement House formed the basis of public health nursing for the entire country. Instead of relying on patients visiting the clinic, public health nurses made their way to the various tenements located around Henry Street (Snodgrass, 2004; Stanhope and Lancaster, 2008). Lillian Wald also developed the first nursing service for occupational health. She believed that prevention of disease among workers would improve productivity and was able to convince the Metropolitan Life Insurance Company that her ideas had merit. As a result, nursing agencies, such as those in place at the Henry Street Settlement House, provided skilled nursing 1213 services to employees. Another innovation that emerged from this program was the sliding fee scale, by which patients were billed according to their income or their ability to pay. This innovative nursing service existed for 44 years before it was dissolved by the Metropolitan Life Insurance Company (Stanhope and Lancaster, 2008). In 1911 Wald chaired a committee formed by members of the Associated Alumnae of Training Schools for Nurses, later to become the American Nurses Association (ANA), and the Society of Superintendents of Training Schools for Nurses, the precursor of the National League for Nursing (NLN). The purpose of the committee was to develop standards for nursing services performed outside of the hospital environment. The committee determined that a new organization was necessary to meet the needs of community health nurses. The result of the committee's recommendation was the formation of the National Organization for Public Health Nursing, whose goals were to establish educational and practice standards for community health nursing (Stanhope The ANA and the NLN are still leading nursing organizations today. The ANA has focused primarily on professional aspects of nursing, and the NLN was the only accrediting body for nursing schools until 1996, when the Commission on Collegiate Nursing Education (CCNE), an autonomous arm of the AACN, was established as an agency devoted exclusively to the accreditation of baccalaureate and graduate degree nursing programs (Stanhope and Lancaster, 2008).

During WWI, the U.S. Public Health Service, founded in 1798 to provide

health care services to merchant seamen, was charged with the responsibility to provide health services at the military posts located within the United States. A nurse, "loaned" by the National Organization for Public Health Nursing, established nursing services at U.S. military outposts. The responsibilities of the U.S. Public Health Service continued to grow; eventually it was composed of physicians, nurses, and other allied health professionals, who provided indigent care and practiced in community health programs (Stanhope and Lancaster, 2008).

As a result of the DRG reimbursement system

hospitals were forced to increase efficiency and more closely manage hospital services, including the patient's length of stay, laboratory 1920 and radiographic testing, and diagnostic procedures. Case management and critical pathways were developed to more efficiently manage patient care, and case management became a new area of specialization for the professional nurse.

Toward the end of the 1980s, the American Medical Association announced its answer to the nursing shortage.

it proposed to establish a 9-month program to prepare registered care technologists. This proposal incensed nurses who unified to fight against it. As a result, the proposal was rejected

The focus of managed care was on providing more preventive and primary care

using outpatient and home settings when possible, and limiting expensive hospitalizations. Massive downsizing of hospital nursing staff occurred, with an increased use of unlicensed assistive personnel to provide care in hospitals. There was an increasing demand for community health nurses and advanced practice nurses to provide primary care services. The nurse of the 1990s had to be focused on delivering health care services that (1) encompassed health risk assessment based on family and environmental factors, (2) supported health promotion and disease prevention, and (3) advanced counseling and health education (Jones, 2004).

The piece of legislation that had the greatest effect on health care in the United States was the Social Security Act of 1935,

which set the precedent for the passage of the Medicare and Medicaid acts that followed in 1965. The main purposes of the 1935 Social Security Act were to provide (1) a national old-age insurance system, (2) federal grants to states for maternal and child welfare services, (3) vocational rehabilitation services for the handicapped, (4) medical care for crippled children and blind people, (5) a plan to strengthen public health services, and (6) a federal-state unemployment system (Karger and Stoesz, 2005). The passage of the 1935 Social Security Act provided avenues for nursing care, and nursing jobs were created. With funds from the Social Security Act, public health nursing became the major source of health care for dependent mothers and children, the blind, and crippled children. Nurses found employment as public health nurses for county or state health departments 1516 (Chitty and Black, 2007). Hospital job opportunities also were created for nurses, and the hospital became the usual employment setting for graduate nurses.

In 1990 the increasing costs of Medicaid and Medicare triggered political action for health care reform. Findings of a federal commission appointed to evaluate the American health care system included the following (Chitty and Black, 2007):

♦Fifteen percent of the gross national product was related to health care expenditures (this amounts to approximately $1 trillion annually). ♦The United States spent more than twice as much as any industrialized nation for health care services. 2122 ♦Americans were living longer, which indicated a growing demand for home health and nursing home care, in addition to increased Medicare expenditures. It became apparent that if health care spending continued to increase, the U.S. economy would be in danger of collapse. Thus the health care system moved toward managed care in an attempt to control health care expenditures. The managed care movement has had a tremendous effect on nursing.