Nursing

DEFINITION: A helping profession that focuses on the care of the sick and disabled and on the maintenance of the health and well-being of all individuals

The Role of Nursing

It is difficult at times to distinguish nursing from medicine, since there are so many ways in which they interrelate. Though some people think that nursing began with Florence Nightingale (1820–1910), it is in fact as old as medicine itself. Throughout history, there have been periods when the two fields functioned interdependently and times when they were practiced separately from each other. It seems likely that many of the seeds of medical knowledge were sown by the natural remedies used by traditional mother-nurse figures.

Over the course of human history, the words "nurse" and 'nursing" have had many meanings, and the connotations have changed as tribes became highly developed nations. The word "nurse" comes from the Latin nutrix, which means “nursing mother.” The word "nursing" originated from the Latin nutrire, meaning “to nourish.” The word "nurse" as a noun was first used in the English language in the thirteenth century, being spelled “norrice,” then evolving to “nurice” or “nourice,” and finally to the present “nurse.” The word "nurse" as a verb meant to suckle and to nourish. The meanings of both the noun and the verb have expanded to include more and more functions related to the care of all human beings. In the sixteenth century, the meaning of the noun included “a person, but usually a woman, who waits upon or tends the sick.” By the nineteenth century, the meaning of the verb included “the training of those who tend the sick and the carrying out of such duties under the supervision of a physician.”

With the origin of nursing as mother care came the idea that nursing was a woman’s role. Suckling and nurturing were associated with maternal instincts. Ill or helpless children were also typically cared for by their mothers. The image of the nurse as a loving and caring mother remains popular. The true spirit of nursing, however, has no sex or gender barriers. History has seen people of all identities respond to the needs of the sick.

The role of the nurse has certainly expanded from that of the mother in the home, nourishing infants and caring for young children. Care of the sick, infirm, helpless, elderly, and handicapped and the promotion of health have become vital aspects of nursing as a whole. Throughout history, the role of nursing developed with the culture and society of a given age. Tribal peoples practiced nursing as they cared for the members of their own families or tribes. As societies grew, nursing began to be practiced outside the home. Nursing care became more complex, and qualities other than a nurturing instinct were needed to do the work of a nurse. Members of religious orders—especially those composed of women—responded by devoting their lives to study, service, and self-sacrifice in caring for the needs of the sick. These individuals were among the educated people of their time, and they helped set the stage for nursing to become an art and a science.

It was not until the nineteenth century that the basis of nursing as a profession was established in Western society. The beliefs and examples of Florence Nightingale laid that foundation. Nightingale was born in Italy in 1820, but she grew up in England. Unlike many of the children of her time, she was educated by governesses and by her father. Against the wishes of her family, she trained to be a nurse at the age of thirty-one. Amid enormous difficulties and prejudices, she organized and managed the nursing care for a military hospital in Turkey during the Crimean War. She returned to England after the war, where she established a school, the Nightingale Training School for Nurses, to train nurses. Again, she encountered great opposition, as nurses were considered little more than housemaids by the physicians of the time. Because of her efforts, the status of nurses was raised to a respected occupation, and the basis for professional nursing in general was established.

Nightingale’s contributions are noteworthy. She recognized that nutrition is an important part of nursing care. She instituted occupational and recreational therapy for the sick and identified the personal needs of the patient and the role of the nurse in meeting those needs. Nightingale established standards for hospital management and a system of nursing education, making nursing a respected occupation for women. She recognized the two components of nursing: promoting health and treating illness. Nightingale believed that nursing is separate and distinct from medicine as a profession.

Nightingale’s methods and the response of nursing to American Civil War casualties in the 1860s pointed out the need for nursing education in the United States. Schools of nursing were established, based on the values of Nightingale, but they operated more like apprenticeships than educational programs. The schools were also controlled by hospital administrators and physicians. In 1896, nurses in the United States banded together to seek standardization of educational programs, to establish laws to ensure the competency of nurses, and to promote the general welfare of nurses. The outcome of their efforts was the American Nurses Association. In 1900, the first nursing journal, the American Journal of Nursing, was founded.

The effects of World War II also made clear the need to base schools of nursing on educational objectives. Many women had responded to the need for nurses during the war. A great expansion in medical knowledge and technology had taken place, and the roles of nurses were expanding as well. Nursing programs developed in colleges and universities and offered degrees in nursing to both women and men. Such developments shaped approaches to nursing through the late twentieth century and into the twenty-first.

While there were major changes in the expectations and styles with which nursing care has been delivered from ancient times into the modern era, the role and function of the nurse have been and continue to be diverse.

The nurse is a caregiver, providing care to patients based on knowledge and skill. Consideration is given to physical, emotional, psychological, socioeconomic, and spiritual needs. The role of the nurse-caregiver is holistic and integrated into all other roles that the nurse fulfills, thus maintaining and promoting health and well-being.

The nurse is a communicator. Using effective and therapeutic communication skills, the nurse strives to establish relationships to assist patients of all ages to manage and become responsible for their own health needs. In this way, the nurse is also a teacher who assists patients and families to meet their learning needs. Individualized teaching plans are developed and used to accomplish set goals.

The nurse is a leader. Based on the self-confidence gained from a nursing education and experience, the nurse is able to be assertive in meeting the needs of patients. The nurse facilitates change to improve care for patients, whether individually or in general. The nurse is also an advocate. Based on the belief that patients have a right to make their own decisions about health and life, the nurse strives to protect their human and legal rights in making those choices.

The nurse is a counselor. By effectively using communication skills, the nurse provides information, listens, facilitates problem-solving and decision-making abilities, and makes appropriate referrals for patients.

Finally, the nurse is a planner, a task that calls forth qualities far beyond nurturing and caring. In an age confronted with controversial topics such as abortion, organ transplants, the allocation of limited resources, and medical research, the role of nurses will continue to expand to meet these challenges in the spirit that allowed nursing to evolve and become a respected profession.

Science and Profession

While the nurse-mother of ancient times functioned within a very limited framework, the modern nurse has the choice of many careers within the nursing role. The knowledge explosion of the twentieth century created many job specialties from which nurses can choose a career. The clinical nurse specialist is a nurse with experience, education, or an advanced degree in a specialized area of nursing. Some examples are enterostomal therapy, geriatrics, infection control, oncology, orthopedics, emergency room care, operating room care, intensive and coronary care, quality assurance, and community health. Nurses who function in such specialties carry out direct patient care; teach patients, families, and staff members; act as consultants; and sometimes conduct research to improve methods of care.

The nurse practitioner is a nurse with an advanced degree who is certified to work in a specific aspect of patient care. Nurse practitioners work in a variety of settings or in independent practice. They perform health assessments and give primary care to their patients.

The nurse anesthetist is a nurse who has also successfully completed a course of study in anesthesia. Nurse anesthetists make preoperative visits and assess patients prior to surgery, administer and monitor anesthesia during surgery, and evaluate the postoperative condition of patients.

The nurse midwife is a nurse who has successfully completed a midwifery program. The nurse midwife provides prenatal care to expectant mothers, delivers babies, and provides postnatal care after the birth.

The nurse administrator functions at various levels of management in the health care field. Depending on the position held, advanced education may be in business or hospital administration. The administrator is directly responsible for the operation and management of resources and is indirectly responsible for the personnel who give patient care.

The nurse educator is a nurse, usually with a master’s degree, who teaches or instructs in clinical or educational settings. This nurse can teach both theory and clinical skills.

The nurse researcher usually has an advanced degree and conducts special studies that involve the collection and evaluation of data in order to report on and promote the improvement of nursing care and education.

Duties and Procedures

Creativity and education are the keys to keeping pace with continued changes and progress in the nursing profession. Nurses are expected to play many roles, function in a variety of settings, and strive for excellence in the performance of their duties. A service must be provided that contributes to the health and well-being of people. The following examples of nursing—an operating room nurse and a home health nurse—provide a limited portrait of how nurses function and what roles they play in medical care.

Operating room nurses function both directly and indirectly in patient care and render services in a number of ways. Operating room nurses, usually known as circulating nurses, briefly interview patients upon their arrival at the operating room. They accompany patients to specific surgery rooms and assist in preparing them for surgical procedures. They are responsible for seeing that surgeons correctly identify patients prior to anesthesia. They are also directly attentive to patients when anesthesia is first administered.

Circulating nurses perform the presurgical scrub, which is a cleansing of the skin with a specified solution for a given number of minutes. It is their overall responsibility to monitor aseptic (sterile) techniques in certain areas of the operating room and to deal with the situation immediately if aseptic techniques are broken. They count the surgical sponges with surgical technologists before the first incision is made, throughout the procedure as necessary, and again before the incision is closed. They secure needed items requested by surgical technologists, surgeons, or anesthesia personnel: medications, blood, additional sterile instruments, or more sponges. At times, they prepare and assist with the operation of equipment used for surgeries, such as lasers, insufflators (used for laparoscopic surgery), and blood saver and reinfuser machines. They arrange for the transportation of specimens to the laboratory. They may also be instrumental in sending communications to waiting family members when the surgery takes longer than anticipated. When the surgery is completed, they accompany patients to the recovery room with the anesthesia personnel.

Home health nurses, on the other hand, function in a very different manner. This type of nurse usually works for a private home health services agency, or as part of an outreach program for home services through a hospital. Referrals come to the agency or program via the physician, through the physician’s office, by way of the social services department in a hospital, or by an individual requesting skilled services through the physician.

The following scenario is an example of a patient whom a home health nurse may be requested to see: a seventy-six-year-old man who was hospitalized with a recent diagnosis of diabetes mellitus, for which he is now insulin-dependent. He also has an open wound on his right ankle. The number of days allowed for hospitalization for his diagnosis has expired, but he still needs help using a glucometer to take his blood sugar readings and assistance with drawing up his insulin. He still has questions about how to manage his diabetes, especially the dietary parameters. He is unable to manage the wound care on his right ankle. His wife is willing to assist him, but she has no knowledge about diabetes or wound care.

The home health nurse performs the following assessments on the initial visit: general physical condition, the patient’s level of knowledge and understanding and his ability to manage his diabetic condition, all medications used, and the patient’s understanding of the actions, side effects, and interactions of these medications. An assessment is made of the home setting in general: the patient’s safety, the support system, and any special needs, such as assistive devices. If services such as physical therapy, speech therapy, or occupational therapy are needed, the nurse makes these referrals. If the patient requires additional in-home services, a referral to a medical social worker is made. Wound care is performed, and the nurse will then set up a plan of care, with the patient’s input, for follow-up visits. Guidelines requested by the physician, as well as approval needed by health insurance companies covering the cost for home health services, will be taken into consideration when planning ongoing visits. If the home health agency has a nurse who is a diabetic specialist, the nurse can either consult with that specialist about the care of this patient or have the diabetic specialist make a home visit.

Perspective and Prospects

From the beginning of human history, nursing and the role of the nurse have been defined by the people and the society of a particular age. Nursing as it is known today is still influenced by what occurred over the centuries.

In ancient times, people tended to believe that illness was supernatural, caused by evil gods or spirits. In many societies, the precursor roles of the physician and the nurse were separate and closely informed by gender norms. The physician was a medicine man, sometimes called a shaman or a witch doctor, who treated disease by ritualistic chants, by fear or shock techniques, or by methods such as boring holes into a person’s skull with a sharp stone to allow the evil spirit or demon an escape. The nurse, on the other hand, was usually the mother figure who tended to family members and provided for their physical needs, using herbal remedies when they were ill.

This gendered division of labor continued as larger civilizations developed. In influential cultures such as Ancient Egypt and Ancient Greece, the centers for medical care were typically temples and the physician was often synonymous with the priest. These priest-physicians were generally male and held a powerful position in society. The nurse figure was a woman, sometimes seen as a slave, who worked in support of the priest-physician. It is in this era that the earliest written records of nursing as a distinct profession originate. The proliferation of hospitals under the Roman Empire helped drive the formalization of nursing positions.

Some ancient nursing practices would go on to have deep influence on Western health care philosophies. The Hebrew tribes used the Ten Commandments and the Mosaic Health Code to develop standards for ethical human relationships, mental health treatment, and disease control. Nurses visited the sick in their homes, practiced as midwives, and provided for the physical and spiritual needs of family members who cared for the ill. These nurses provided a family-centered approach to care.

With the advent of Christianity, the value of the individual was emphasized, and the responsibility for recognizing the needs of each individual emerged. Nursing gained an elevated position in society. A spiritual foundation for nursing was established as well. The first organized visiting of the sick was done by deaconesses and Christian Roman matrons of the time. Members of male religious orders also cared for the sick and buried the dead.

During the medieval period there were both male and female nursing orders. Men usually belonged to military nursing orders, who cared for the sick, on one hand, and defended the hospital when it was under attack, on the other. While nursing long remained a respected vocation, the medical care landscape continued to evolve with society in general, and not always in positive ways. Hospitals became a place to keep, not cure, patients. Nursing care was largely custodial, and the practice of accepting individuals of low character to supplement inadequate nursing staffs became common. Challenges were augmented by the fact that there were no methods of infection control.

The era from approximately 1500 to 1860 was a low point in nursing history. Nursing at this time was not a highly regarded profession in Western society. Women who had committed a crime were sometimes sent into nursing as an alternative to serving a jail term. Nurses received poor wages and worked long hours under deplorable conditions. Changes in the Reformation and the Renaissance did little or nothing to improve the care of the sick. The attitude prevailed that nursing was a religious and not an intellectual occupation. Charles Dickens quite aptly portrayed the nurse and nursing conditions of the time through his caricatures of Sairey Gamp and Betsey Prig in Martin Chuzzlewit (1843–1844).

It was not until the middle of the nineteenth century that this situation began to change. Through Florence Nightingale’s efforts, nursing became a respected occupation once more, the quality of nursing care improved tremendously, and the foundation was laid for modern nursing education. In the twentieth century nursing evolved in parallel with science-driven improvements in medicine in general. Training and practice became increasingly standardized as well as specialized, with many educational programs and professional organizations supporting nursing careers. There was also increasing formalization and development of nursing theory.

In the early twenty-first century nursing remained deeply intertwined with all aspects of the broad fields of medicine and health care. Notably, nursing reflected many hot-button social issues, including complex political and cultural intersections. In the United States, one major topic of debate was the concept of legal limits on the number of patients that could be assigned to a nurse during their shift. Advocates of such measures argued that limits would take pressure off frequently overworked nurses and lead to improved treatment results. Opponents argued that such limits would require hiring additional staff and cutting costs in other crucial areas, negatively impacting overall care. California was an early adopter of patient limits, and other states considered similar legislation in the 2010s and 2020s.

Connected to this debate was a significant ongoing shortage of nurses in the United States, as reported by the US Bureau of Labor Statistics in 2020. That same year, nurses around the world faced extra challenges amid the coronavirus disease 2019 (COVID-19) global pandemic, which strained the capacity of many hospitals and deeply disrupted society in many ways. In addition to having to work longer hours in a high-stress environment, many health care workers had limited accessed to personal protective equipment like masks and dealt with ever-changing guidelines for dealing with the disease. Such incidents brought much public attention to nursing, and in some cases even a reevaluation of the profession's fundamental role in society.

As innovations in health care have an impact on nursing, nurses’ roles will continue to expand in the future. Nursing can also be a background from which people begin to bridge gaps of service where other affiliations are needed: computer science, medical-legal issues, health insurance agencies, and bioethics, to name a few. The words of Florence Nightingale still echo as a challenge to the nursing profession:

May the methods by which every infant, every human being will have the best chance of health, the methods by which every sick person will have the best chance of recovery, be learned and practiced! Hospitals are only an intermediate state of civilization never intended, at all events, to take in the whole sick population.

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