Nursing
in the 20th century

In 1912, Lillian Wald, seen in the image above, was a pioneer in providing public health nursing services in both urban and rural areas.

Some of the first African-American nurses to serve with the U.S. Army stand outside their quarters at Camp Sherman in Chillicothe, Ohio, at the beginning of the century.
<click photo to see larger image>

By Leigh Morgan
Images courtesy of the American Red Cross and the U.S. Army Nurse Corps
Illustrations by Malcolm Garris
May 2, 1998

If you had been born in a different era, would you have wanted to be a nurse?

Think about what your daily routine might have been. In the early 1900s, you would have spent your time sterilizing equipment and administering leeches. In the middle of the century, you would have been at the patient’s bedside often, but you still may have sharpened needles two days a week. As recently as the’80s, you wouldn’t have known what a personal computer was, let alone used one to access information.

There’s no doubt that nursing roles have changed dramatically throughout the 20th century, and for the better, according to many nurse historians. Here are some of the highlights in the evolution of contemporary nursing.

Early 1900s
More than a maid

In the early 20th century, most nurses received their education from hospitals, not colleges or universities. While earning diplomas at hospital-based schools, student nurses provided the facility with two to three years of cheap and abundant labor, typically working 10- to 12-hour shifts seven days a week, with only a few hours dedicated to classroom instruction. Historians describe early clinical training programs as rigorous and exhausting.

A new nursing student, known as a probationer, often began working primarily as a maid—dusting, scrubbing, and washing dishes—under the scrutiny of a superintendent. Above all, the probationer adhered to a code of etiquette that required utter deference to physicians and supervisors. If she passed muster, the student could expect to move on to more patient-oriented duties.

"Every nurse in our School has from four to six weeks’ training in operating room work alone," wrote a probationer in 1899 at the Orange Training School for Nurses in New Jersey. "During this time she has to make up and keep on hand thousands of sponges, wipes, bandages, and dressings of all kinds, and attend to the sterilization of the same. She prepares all the water used by boiling and filtering it three times and then bottling it; she sterilizes sutures and ligatures; keeps the instruments bright and clean; and is responsible for the perfect cleanliness of the operating room."

After graduating, a nurse in the early 1900s usually went to work as a private-duty nurse in a patient’s home or as a superintendent in a hospital. According to the Department of Labor, private-duty nurses averaged about $5 a week near the turn of the century—barely enough to live on.

The vast influx of immigrants to the United States fueled a boom in public health nursing in the early 1900s, said Stephanie Tabone, RN director of practice for the Texas Nurses Association. From 1820 to 1910, nearly 30 million immigrants arrived in America, many settling in slums and tenement housing within major cities. "At the turn of century, these visiting nurses went out to people’s homes all over the country and taught them about cleanliness, nutrition, and child care to decrease disease and suffering in these poor environments," she said. In 1912, the National Organization for Public Health Nursing was founded.

Nursing often boiled down to housekeeping during this period, said Vern Bullough, PhD, RN, FAAN, a historian and sociologist, and visiting professor of nursing at the University of Southern California. Nurses spent hours sweeping, mopping, dusting, polishing, cooking meals, stoking coal stoves, filling kerosene lamps, cleaning chimneys, and washing and folding linens. By the 1920s, nurses still earned low wages—about 50 cents an hour, Bullough said.

Nurses’ caregiving duties included giving baths, inserting catheters, administering enemas and medications, dressing wounds and sores, and generally monitoring patients’ appearance. In the early 1900s, nurses still administered leeches to treat inflammations or engorgement and relied heavily on poultices, stupes, and plasters to relieve everything from congestion to colic.

No longer reserved for the indigent and the dying, hospitals during this time were being transformed into mainstream institutions where the middle class went for treatment and childbearing, said Barbara Brodie, PhD, RN, FAAN, professor in the school of nursing at the University of Virginia in Charlottesville and director of the Center for Nursing Historical Inquiry.

World War II
Move to the bedside

"World War II was a major turning point for nurses," said Mary Ellen Doona, EdD, RN, associate professor of nursing at Boston College and a historian for the Massachusetts Nurses Association. "For the first time, nurses were out of the hospital, where they had been very constrained by rules and procedures, and were really at the patient’s bedside, making their own choices based on their own judgment and dealing with the consequences. They were discovering that’s what nursing is all about."

As nurses joined the war effort, civilian hospitals that had sprung up around shipyards and military bases became short-staffed. In 1943 Congress initiated the Cadet Nurse Corps Program to subsidize education for nursing students who promised to work in underserved areas for the duration of the war. Over 150,000 nurses gained training through the program over the next three years, according to the U.S. Army Center for Military History. During a brief shortage of military nurses in 1945, more than 100,000 Cadet Nurse Corps trainees volunteered for duty.

Overall, some 200 nurses died while serving the Army in World War II and over 1,600 received medals or other honors for their efforts.

Nurses returned from the war armed not only with solid public support, but with new skills. The military had trained nurses in specialties such as anesthesia and psychiatric care, and offered valuable hands-on experience that would ultimately broaden the scope of the profession for future generations.

After the war, the nation’s economy and huge appetite for health care enabled nurses to seek more independence and education, Brodie said. "We emerged from that war one of the richest countries in the world and with a great belief in the power of science and the federal government to solve our problems. Congress passed acts that poured billions into health care. That’s when medical insurance became part of employment packages."

A pharmaceutical revolution followed, Brodie said. Penicillin drastically changed health care by curing infections and allowing more invasive surgeries. Other advances included TB treatments, the polio vaccine, new contraceptives, anti-inflammatory drugs, and even Valium.

Despite the modernization of health care, some aspects of nursing still lagged in the 1950s. Donna F. Ver Steeg, PhD, RN, FAAN, a researcher of healthcare manpower who graduated from nursing school in 1950, said she remembers preparing an injection by mashing pills in a mortar, heating the powdered mix in a teaspoon over an open flame, and drawing the liquid into a glass syringe.

Hospitals still strapped oxygen tanks to patients’ beds in the 1950s and didn’t have much disposable equipment. Nurses still autoclaved catheters and sharpened needles.

1960s and after
Break with tradition

Historians point to numerous changes in health care, medicine, and nursing during this decade. "In the’60s, the intensive care unit was developed," Doona said. "With ICUs you have top-level doctors and nurses taking care of acutely ill patients. The technology drove a higher level of training, so you get specialization in nursing and, along with that, advanced degrees."

The big development in the ’60s was the nurse practitioner movement. "These were nurses who were semi-independent and did many of the things physicians had done," Bullough said. With most hospital nursing schools closing by this time, "there was an attempt to have everybody become a baccalaureate-prepared nurse."

By the late ’60s, cutting-edge hospital equipment was relatively user-friendly, so machines could be easily operated by nurses, Ver Steeg said. "That meant that nurses were staffing ICUs 24 hours a day, taking blood pressure, reading heart monitors, and doing all the high-tech stuff. Doctors were beside themselves. It was clear that nurses were practicing medicine." Ver Steeg said physicians resisted the advent of advanced practice nurses, but ultimately gave way to the public pressure that favored the shift. "Nurse practitioners started existing by the late ’70s as a separate legal entity in some states," Ver Steeg said.

Today
Increasing responsibility

In recent decades, nurses have become much more responsible for the care and monitoring of patients, as well as more collaborative and accountable, Brodie said. Tabone said she sees nursing "going back to the future" with an emphasis on public health care rather than hospital-based nursing. "In the coming paradigm shift in the delivery of health care, nurses will have a greater educational role outside institutions, identifying ways to keep entire populations healthy," she said. For example, nurses will work in greater numbers as disease managers, case managers, home health providers, clinic-based providers, and parish nurses. "These things are the future of the profession. Not new pumps and better surgical procedures, but actually dealing with the health of communities and empowering people to have the greatest optimum health possible. "In some ways that’s what nursing started out doing at the turn of the century," Tabone said.

Before going on duty, Army nurses stand in front of the 13th Station Hospital, Australia, 1943.
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