Historical development of nursing as a profession

Abstract

Although the practice of nursing can be traced back thousands of years, the history of modern nursing as a profession begins with the integration of evidence-based practice. Evidence-based practice has dramatically, profoundly, and irreversibly altered standards of healthcare services around the world. Similarly, evidence-based practice has changed the methods of nursing education to improve core competencies and promote a focus on patient outcomes. The social history method is used to evaluate the primary research question, which is how the integration of Evidence-Based Practice impacted nursing in the educational and practice domains from 1870 to 1920. Using the social history method reveals the contextual variables that facilitated Florence Nightingale’s own work, which established the precedent for evidence-based practice. A combination of primary and secondary sources allows for a deeper, richer understanding of the importance of evidence-based practice and the impact on nursing in terms of improved self-concept, self-efficacy, and legitimacy.

Introduction

In the 21st century, it is presumed that healthcare practice is evidence-based, rather than arbitrary, inconsistent, or based on spurious superstition or religious beliefs. However, it was only a century ago that the struggle to integrate scientific principles into nursing practice continued. Formal nursing practice evolved in Europe and the United Kingdom as an offshoot of religious service, provided by nuns. A social history research methods approach shows how the gradual secularization of European society caused a crisis in healthcare, a crisis that Florence Nightingale recognized and helped to resolve during her work during the Crimean War. The realities of modern warfare revealed the need for improved standards of care. Nightingale applied the scientific method, empiricism, and qualitative research methods into her work as a nurse, something that had never before been done with the same degree of certainty. In 1859, Nightingale published Notes on Nursing, which established evidence-based practice and set the stage also for formalized nurse training and education.

How did the integration of Evidence-Based Practice impact nursing in the educational and practice domains from 1870 to 1920? This research question is best approached using the social history research method. Social history research methods take into account not just facts and figures but also contextual variables. Historical realities, social contexts, and issues like class, gender, and power all have a bearing on the evolution of education and practice domains in nursing. It is hypothesized that the integration of evidence-based practice into nursing by Nightingale led directly to the professionalization of nursing. Professionalization entails rigorous standards for the education and training of nurse practitioners, as well as standardized care practices that respond to emerging research in science and medicine.

Social History Research Method, Rationale, and Sources of Information

Prior to the professionalization of nursing, patients were treated and considered inseparable from their social contexts. Patients’ biographical information, their psychosocial state, and other personal factors were deemed crucial to the healing process or at least necessary for understanding any presenting physical ailments or problems (“Social History,” 2012). Integrating contextual variables into the study and practice of nursing constitutes the essence of the social history research method. Social history approaches to research take into account contextual and environmental factors impacting nursing practice, including patient outcomes. Similarly, the social history research method promotes a fuller understanding of nursing history. The social history approach is embedded in the history of nursing itself.

As the disciplines of sociology and psychology began to weave their ways into healthcare in general, the role of nurses and the nursing profession expanded. During the late 19th and early 20th century, healthcare was in fact used as a form of social control, via the processes of labeling (Dingwall, Rafferty & Webster, 1988). Placing the history of nursing within a social, cultural, and historical context allows for a richer understanding of the subject, which is why this is the most appropriate method for exploring the research question. In fact, it can be considered impossible to acknowledge the role of evidence-based practice in early nursing history without the social history approach. Artificially segregating the core events in nursing history from their social contexts would lead to an incomplete assessment of the research question.

Social histories are firsthand accounts from those that actually experienced the event or those that have interpreted the events as they happened. Samuel (2017), for instance, points out that social history focuses on “real life” and “ordinary people,” (p. 1). Social history approaches help reveal the variables that precipitated an event, led to a theoretical viewpoint, or caused a particular person to act or behave in certain ways. Moreover, the social history method focuses on average people to eliminate elitism and minimize bias in research. Social history specifically gives an insight into how ordinary women lived their lives and reacted to burgeoning integration of science into nursing methodology during the research era. Sources of information for the current research include both primary and secondary sources such as those written by or about Florence Nightingale.

Findings and Discussion

The integration of evidence-based practice has impacted the nursing profession since its inception, and particularly since the contributions of Florence Nightingale. Primary sources available through the UK’s National Archives (n.d.) reveal the social, cultural, and historical contexts that surrounded the initial evolution of evidence-based practice in nursing. As a wartime nurse, Nightingale recognized the need for evidence-based practice by cataloguing patients, organizing nursing staff, and effectively delivering patient-centric care that maximized measurable outcomes that Nightingale documented in written reports (National Archives, n.d., Source 2). From within this specific context, Nightingale understood the importance of ongoing documentation and information sharing to improve performance outcomes. Furthermore, the historical and social context of the late 19th century gave rise to increased use of science methodologies in all practice spheres, particularly in medicine. Folk wisdom and superstition gave way to full-on acceptance of the efficacy of research, evidence, and the scientific method.

Professionalization was also a social and historical trend in multiple practice spheres. Educational institutions would train practitioners, representing a shift from prior practices that disempowered those without access to education, especially women. Wartime revealed the need to obliterate gender bias in nursing practice, leading to the feminization of the nursing profession. Men were the soldiers and therefore became the primary patient demographic treated by Nightingale and her female staff (National Archieves, n.d.). The professionalization of nursing occurred concurrently with the professionalization of other practice domains, not just in medicine, but in education itself. Therefore, nursing became professionalized and Nightingale called for standards in nursing education that would properly prepare nursing staff for their roles, responsibilities, and duties.

During the critical era of nursing professionalization between 1870 and 1920, evidence-based practice informed nursing methodology, education, and practice. Nightingale not only based nursing education on the concept of professionalization; she also “started the concept of improving patient outcomes through sound evidence,” (Mackey & Bassendowski, 2017, p. 52). From 1870 to 1920, nurse educators and nurse practitioners capitalized on the example set by Nightingale by incorporating evidence derived from empirical science into both the professionalization of nursing and also into the guidelines for best practices in specific clinical environments. Therefore, the earliest integration of evidence-based practice into nursing is the most important element of the early history of the profession, its education and its practice. Nursing therapeutics and technologies responded to demands for evidence-based services, procedures, and technologies. For example, between 1870 and 1920, researchers and nurses collaborated to “embed antisepsis and asepsis into the nursing curricula at British hospitals,” (Jones, Dupress, Hutchison, et al., 2017, p. 1). In her 1859 publication, Notes on Nursing, Nightingale documented practices such as proper hand washing techniques to contribute to burgeoning research and evidence bases for teaching future nurse practitioners. In fact, the detailed information on sanitation and the importance of antiseptic conditions to improving patient care were rooted on Nightingale’s knowledge of emerging scientific data on germs and pathogens. Nightingale also became the first female member of the Royal Statistical Society because she believed that statistics and numbers were necessary for improving patient outcomes (National Archives, n.d.). Transformations in actual hospital policy and praxis evolved considerably during the late 19th and early 20th centuries, as a result of Nightingale’s contributions. Between 1870 and 1920, training manuals for nurses enhanced consistency and accuracy in patient care, while nursing became increasingly secularized to reduce the infiltration of religion into science (Bartoloni & Canalejo, 2011). Technological advancements in medicine became increasingly based on scientific research that was sponsored by universities, and eventually, nurse education became university-based to reflect the change in perspective.

Both the educational and practice domains benefitted from the bilateral communication that ensued between practitioners and researchers. Research informed evidence-based practice and transformed nursing curricula and pedagogy, while practice helped to inform research questions, the evolution of different nursing theories, and also guide the framing of hypotheses. The impact of evidence-based practice on nursing is comprehensive, including improving the self-concept of the profession of nursing, and the individual self-efficacy of nurses. Evidence-based practice has legitimized the nursing profession, instituting standards for nursing education. The overall impact of evidence-based practice has been “to standardize healthcare practices to science and best evidence and to reduce illogical variation in care, which is known to produce unpredictable health outcomes,” (Stevens, 2013, p. 1). Nurses are recognized for high standards and core competencies because of evidence-based practice, stemming from the initial contributions of Florence Nightingale.