By Anne Federwisch
December 13, 1999
Photos: American Red Cross/Corbis

At first glance, you might not think that nurses of 1900 had much in common with their present-day counterparts. But you’d be wrong. Sure, there are significant differences. The nurses of old wore caps and capes rather than colorful scrubs and street clothes. They discarded their profession when they married. Even the self-taught could call themselves nurses since state boards had not yet been established. Those who did get formal training at the turn of the last century primarily progressed from hospital-based programs to private-duty practice, while the nurses on the cusp of the new millennium have several educational and treatment venues from which to choose. And many of the standard supplies used daily by nurses today weren’t even on the drawing board 100 years ago. But despite the significant evolution, the core of nursing has remained constant, experts insist.

“Nursing is still about a one-to-one relationship between a nurse and a patient,” said Marie Manthey, MNA, RN, president emeritus of the Minneapolis-based consulting company Creative HealthCare Management.

“We have a much bigger knowledge base, a much bigger science that we’re dealing with now,” said Karen Buhler-Wilkerson, PhD, RN, FAAN, professor of community health and director of the Center for the Study of the History of Nursing at the University of Pennsylvania School of Nursing. But, she stressed, “Nursing is still about caring.”

Nursing a century ago

Without antibiotics or modern medical equipment, nursing care was crucial in treating the infectious diseases rampant in 1900, Buhler-Wilkerson said. “Highly skilled nursing care oftentimes meant the difference between life and death because there wasn’t treatment for a lot of disease,” Manthey noted. Nursing care centered on fever reduction, antiseptic techniques, good skin care, health education, and proper nutrition. “Nurses would really manage everything about a patient’s life and environment,” Buhler-Wilkerson said.

Student nurses staffed the hospitals of the day. They began their professional careers while they learned their craft through hospital training programs. Upon graduation, they had three options: hospital supervisory roles, public health, or private duty. “Very few, the select few, would become superintendents of nursing or teach nursing,” said Joan Lynaugh, PhD, RN, FAAN, professor emeritus of the University of Pennsylvania School of Nursing and associate director of the Center for the Study of the History of Nursing.

Another elite group joined the burgeoning public health movement, Buhler-Wilkerson said. But the majority provided private duty care to the relatively affluent. With no insurance programs, nursing care cost about $4 a day. So only the well-to-do or the extremely poor recipients of public care had access to nursing care at the time, Lynaugh said.

The typical nurse was a young single woman. (Married nurses didn’t gain societal approval until after World War II.) Those working private duty usually placed their names on central registry lists. “Making the match between the doctor, the family, and the nurse was really pretty complicated,” Buhler-Wilkerson said. “If the nurses had work steadily, they made a decent living.”

Training and nursing practice varied greatly at this time. State boards were just beginning to emerge in the early 1900s. “When the state boards began, that entitled nurses to be RNs,” said Susan Mayer, EdD, assistant professor of nursing at the Helene Fuld College of Nursing in New York City.

Rise of academic training

Around 1912, the U.S. Bureau of Education issued a report called The Educational Status of Nursing. By focusing on what and how students were being taught, “it began to establish nursing as a profession,” Mayer said.

Educational programs outside of hospitals began to pop up around the early 1920s. A few universities began offering bachelor’s degrees in nursing, Lynaugh said, though some of the degrees were in nursing education. “As the bachelor’s degree [came to be seen as] the best type of education, I think that the status of nursing in the eyes of society began to rise,” Manthey said. However, hospital apprenticeships remained the norm for a few more decades. “The output of those [university] programs was really very small until after World War II,” Lynaugh said.

Shift in treatment setting

The ’20s also began a shift in the setting of nursing because private duty nurses faced a glut in the market, Buhler-Wilkerson said. “At that point, there was huge competition for jobs, immense periods between employment,” she said. Graduate nurses began to trickle back to hospitals. With the ’29 stock market crash, they flooded back because “people couldn’t afford private duty nurses,” Manthey said. “Nurses were eating in soup kitchens and standing in bread lines.”

By the ’30s, hospitals routinely hired graduate nurses for two reasons, Lynaugh said. “Nurse wages were so low, they could afford it; and two, the cost of operating [nursing] schools began to be more than some hospitals wanted to pay.”

With the start of World War II, the glut of nurses transformed into a critical nursing shortage. Schools for vocational nurses multiplied to help fill the void.

The huge number of war wounded and the swift development of technology and techniques to treat them proved pivotal in the development of nursing. “All the technology from the battlefield was being brought over to American hospitals, so they were growing in complexity and there weren’t enough nurses,” Manthey said.

Serious growth

A double boom after World War II further fueled the need for nurses. The baby boom sharply increased the population (while taking a lot of trained nurses out of the job market to raise families), and the Hill-Burton Act of 1946, a federal funding grant, spawned a huge hospital building boom.

And with the rise of health insurance, physicians admitted more patients than ever to the hospital. “Things that used to be done outside the hospital were being done inside the hospital,” said Manthey.

Bachelor’s degree programs became more prominent, and by the early 1950s, community colleges started associate degree nursing programs as hospital-based programs phased out. At the same time, clinical nurse specialists and master’s degree-prepared nurses appeared, primarily in the area of psychiatry. “But it was the 1960s before the idea really began to spread outside of psychiatry,” Lynaugh said. Nurse practitioner programs began in the mid-’60s, she said, spurred on by federal funding incentives. By the ’80s, the programs had become popular.

Advanced practice nurses transformed nursing, Manthey said. “It’s the advanced practice role that has put the nursing profession further along the continuum of independence,” she said.

Serious growth

The subsequent rise of nursing research has also helped solidify nursing as a profession with a unique science and body of knowledge, said Margaret Grey, DrPH, RN, FAAN, associate dean for research affairs at the Yale School of Nursing in New Haven, Conn. Although nurses have done research in some fashion since the profession began, it wasn’t as prevalent as it is now.

“Florence Nightingale herself collected data in an organized way to be able to solve clinical problems,” Grey said. But the nursing model at the turn of the century limited research opportunities. “As private duty nurses, they never had contact with multiple patients over a period of time that would allow you to do decent research,” Grey explained. Controlled clinical studies didn’t become the norm until the early ’60s, she said, and have evolved ever since.

As practitioners have engaged in independent research focusing on the nursing point of view (a perspective of caring vs. curing, according to Grey), they have not only advanced the profession, but also transformed the perception others have of the professional. “It made schools of nursing full partners in the academic community,” she said.

The addition of the National Institute of Nursing Research at the National Institutes of Health in 1986 underscored that metamorphosis. “It elevated nursing to an equal status of many of the other biomedical fields,” Grey said.

2000 and beyond

Over the last century, nurses have evolved considerably. They’ve transformed their role to deal with the shift from infectious to chronic diseases, Buhler-Wilkerson said. They’ve elevated their status to that of colleagues or partners with physicians rather than handmaidens, said Beverly Malone, PhD, RN, FAAN, president of the American Nurses Association.

Yet despite the professional and educational advances, nurses have stayed focused on their patients, Mayer said. “Nursing is really the same. There’s still the caring,” she said. “But the tools are different, and we have more tools than we’ve ever had before.”

But nurses likely face further change in the “exciting, but demanding” future, according to Malone. Challenges include dealing with staffing levels, continued competency, patient advocacy and safety, workplace safety, and workplace rights, she said.

“It’s going to be a challenge for nurses, but the future will be one of the most exciting opportunities we will have,” Malone said. That may have been the same sentiment expressed by nursing leaders of the 1900s, as well.