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American Association of Colleges of Nursing

National League for Nursing

By Barbara Tone, RN
December 20, 1999
Photo: Waltham Training School for Nurses Collection, Department for Special Collections, Boston University

A century ago, nobody would have dreamed that nursing education could have changed so much. From the hospital-based programs of the early 1900s to the PhD programs of today, nursing history reflects a series of often slow, but always deliberate, steps to increasing independence and professionalism.

At the turn of the century, all nursing education was done within the hospital setting. Student nurses were responsible for virtually all the care of the hospital’s patients, working more than 50 hours a week, with two half days off. Upon graduation, a very few might be offered the opportunity to stay on to become one of two or three trained nurses working at the hospital. “With the industrial revolution, hospitals became more valuable and saw women as slave labor and really didn’t worry much about education,” said Donna Ver Steeg, PhD, FAAN, emeritus professor at UCLA. “They worried more about getting the most hours out of them.”

By today’s standards, it was a difficult life, but many students at that time saw it differently. “It sounds incredibly hard,” said Joan E. Lynaugh, PhD, RN, FAAN, professor emeritus at the School of Nursing at the University of Pennsylvania in Philadelphia and associate director of the Center for the Study of the History of Nursing. “But the women who wrote at that time were very proud of themselves. They liked the independence and liked learning. They met interesting people and usually lived someplace different than they lived before.”

Increasing standards for training

The early standards for admission, graduation, and curriculum varied dramatically, with some schools asking for only an eighth-grade education for admission while others required high school completion.

In addition, many of those practicing as “nurses” had never received any training at all, prompting a crusade for nurse registration. Several events in the early 1900s, including an announcement by a Philadelphia college that it was launching a school that would prepare nursing students in 10 weeks, led to the beginnings of state registration for nurses.

It wasn’t until the 1920s—60 years after the first training school opened in Boston—that a standard curriculum was developed. Getting a standard curriculum “was quite an achievement,” said Lynaugh. “There were still a lot of scuzzy schools, but most of the schools held to the standard.”

About that same time, the first discussions about university-based nursing education began. In 1918, Adelaide Nutting, a prominent nursing educator, spoke to the Rockefeller Foundation about the need for improved nursing education. The result was the formation of the Committee for the Study of Nursing Education, which released the 500-page study Nursing and Nursing Education in the United States in 1922.

The study, later known as the Goldmark Report for its author, Josephine Goldmark, pushed for university-based nursing programs, launching the beginnings of the battle over whether nurses should be seen as professionals or technicians. Despite the recommendations and the opening of a few baccalaureate programs throughout the country, hospital-based programs continued to dominate. The conflict between the need for student labor and the demand to improve nursing education continued for decades.

Post-war changes

Following World War II, several things altered the educational landscape. The Hill-Burton Act of 1946 created funding for the improvement and expansion of hospital services to the public, creating a huge demand for nurses. It became apparent to hospitals that if they were going to provide competent service to patients in a rapidly changing world, they needed trained nurses rather than students. The costs of running hospital-based programs had also increased significantly, and gradually hospitals began to decrease their objections to collegiate training programs.

About the same time, Esther Lucille Brown, PhD, a researcher for the Russell Sage Foundation, issued a report titled Nursing for the Future, which severely criticized the overall quality of nursing education. Through the Committee to Implement the Brown Report, soon renamed the National Committee for the Improvement of Nursing Services, nursing education finally began its long-discussed move to accreditation.

To meet the ever-growing needs created by Hill-Burton funding and the pressure to take education out of the hospital setting, the first associate degree program was launched in 1952. “The idea really caught on,” Lynaugh said. “These programs coincided with the growth of community colleges, which were also supported by federal funds.”

In the early 1960s, higher education in nursing received a boost with the Kennedy administration's appointment of the Consultative Group on Nursing, which stressed the need for a significant increase in nurses prepared at bachelor’s and graduate levels.

Based on the group’s recommendations, the Nursing Training Act of 1964 was passed, pouring nearly $300 million into nursing education, with $35 million specifically designated for collegiate programs. “While creation of the idea of nursing education would have to be the first milestone in the history of nursing, the Nurse Training Act would have to rank as almost the most significant,” said Lynaugh. “It really moved nursing education into a solid position in the university system so that it could be financially viable as an educational enterprise.”

Technological advances

Post-World War II advances in technology also helped influence nursing education, calling for more and more expertise on the part of graduates. “The transistor, the silicon chip, the laser, and the developments coming out of biological research transitioned nurses from the person who does without thinking to the person who thinks,” said Marjorie Barter, EdD, RN, chair of the graduate department of the University of California, San Francisco School of Nursing. “We became knowledge workers to a much greater extent than before.”

The ’60s saw a substantial increase in the number of nurses at the baccalaureate level, along with the addition of advanced practice and clinical specialization. The ’70s marked an increase in master's preparation and the beginnings of more widespread doctoral programs.

Still evolving

Along with others in health care, nurses in the 1980s and ’90s grappled with the changes brought by efforts to contain rapidly increasing healthcare costs, as well as the debate over how best to prepare nurses for the future. The “technical vs. professional” debate continues, as does the debate over establishing the bachelor’s degree as entry into professional practice.

As the century turns, nursing has moved from some 400 hospital-based programs in 1900 to an educational base that includes 80 doctoral programs, 340 master’s programs, 650 baccalaureate programs, 880 associate degree programs, and 80 hospital-based diploma programs.

By any measure, the profession has reason to be proud of its accomplishments, but to achieve as much in the next century, it must continue to evolve. “In this century, nursing education has been able to adjust fairly rapidly to the meet society’s nursing needs,” said Andrea Lindell, PhD, dean of the College of Nursing and Health at the University of Cincinnati and president of the American Association of Colleges of Nursing. “I hope we can continue to be as responsive.”