Nurses study the historical evolution of the profession to learn lessons from the past. The focus of nursing, which is both an art and a science, has changed from the care of the sick to a more holistic emphasis on health. Nursing began during prehistoric times, when females provided care within families. Monks and nuns who had no formal training for providing care established religious hospitals in the Eastern Roman Empire. Men provided most of the care on the battlefield and in hospitals during the Middle Ages. During the Renaissance and the Industrial Revolution, the science of medicine advanced, but nursing did not. Most nursing care remained in the home. Outside the home, nursing was considered to be inappropriate for proper women. However, by the 1800s, people were cared for in hospitals by women who were either deaconesses or nuns.

The founder of modern nursing was Florence Nightingale, a well-educated young woman who defied the English social mores of her day and graduated from a three-month course in nursing at the Kaiserwerth Institute in Germany. She is credited with reducing morbidity and mortality during the Crimean War. She subsequently founded the Nightingale Training School of Nurses at the St. Thomas Hospital in London. She taught nursing to her students as a profession distinct from medicine. Nightingale provided a holistic model, emphasizing the importance of creating an environment that promotes healing. She promoted good hygiene but did not believe in the germ theory.

The need for formalized nursing began in America during the Civil war. Initially, nuns provided care to both Union and Confederate soldiers, but lay women soon followed their example. Dorothea Dix was named Superintendent of the Female Nurses of the Union Army, where she led 2,000 women in caring for the sick and wounded. After the war, Dix became a leading reformer for the mentally ill. Clara Barton was one of the nurses who volunteered during the Civil War. She founded the Red Cross in 1881 and organized the care of American soldiers during the Spanish-American War in Cuba.

Numerous other nursing pioneers have influenced the development of nursing. For example,

• Lillian Wald founded public health nursing when she established the Henry Street Settlement Service in New York City in 1898, subsequently improving the living conditions for immigrants and starting the Children’s Bureau in the U.S. Department of Labor.
• Isabel Hampton Robb advocated for the rights of student nurses and was instrumental in founding the American Nurses Association and the National League for Nursing.
• Jane Delano was a member of the Army Nurse Corps and a leader in the American Red Cross.
• Annie Goodrich established the Army Training School for Nurses and was the first dean of the Yale University School of Nursing.
• Adelaide Nutting established the nursing program at Teachers College, Columbia University, New York City.
• Lavinia Dock wrote one of the first textbooks for nurses and was the first editor of the American Journal of Nursing.
• Mary Breckinridge founded the Frontier Nursing Service, which provided primary care in Kentucky’s Appalachian Mountains.
• Martha Franklin founded the National Association of Colored Graduate Nurses in 1908, which merged with the American Nurses Association in 1951.
• Amelia Greenwald served as chief nurse in field hospitals during World War I and then founded a school of nursing in Poland. She is considered the stimulus for international public health nursing.
• Mamie Hale improved the science of midwifery.
• Mary Mahoney was an African-American nurse who advocated for multicultural diversity in nursing.
• Harriet Phillips was the first American nurse to receive a training certificate. She was a graduate of the nursing program at Women’s Hospital of Philadelphia.
• Linda Richards founded 10 hospital-based training schools for nurses and subsequently introduced nurse’s notes, physician’s orders, and nursing uniforms.
• Margaret Sanger was a birth control pioneer.
• Shirley Titus, one-time dean of the School of Nursing at Vanderbilt University and executive director of the California State Nurses’ Association, was the first advocate for economic security for nurses.
• Adah Belle Thomas led the effort for equal rights for minority nurses in the American Red Cross and the Army Nurse Corps.

The payment for health services has influenced the history of health care in America. Third-party payment is defined as the payment for an individual’s medical care by a party other than the recipient of care. Prepaid health insurance began in the beginning of the 20th century. The American Hospital Association initiated Blue Cross insurance in 1933 and the American Medical Association developed Blue Shield insurance in 1938. The U.S. federal government initiated third-party payment for medical care for the elderly and the poor with the passage of the Medicare and Medicaid programs in 1965. Prior to the passage of the Health Maintenance Organization of Act of 1973, health insurance provided funding for care on a fee-for-service basis. HMOs provide funding for care based on pre-established fee schedules.

During the 20th century, several landmark reports were published on medical and nursing education. The first was the Flexner report, published in 1910 and funded by the Carnegie Society, a study leading to standardization and improvement in medical education. The Goldmark report, Nursing and Nursing Education in the United States, was published in 1923. The Goldmark report recommended that nursing education be moved into mainstream university education and that the learning needs of nursing students should have precedence over the hospital’s need for workers.

The 1948 Brown report, Nursing for the Future and Nursing Reconsidered: A Study for Change, reiterated these recommendations. This study, by social anthropologist Esther Lucille Brown, noted that hospital training schools had not changed significantly from a service to an educational model. Later studies in the 1980s, by the National Commission on Nursing, the Institute of Medicine, and the Health and Human Services Secretary’s Commission on Nursing, recommended improvements in nursing education, improvements in working conditions for nurses, expansion of the nursing role, and collaboration between physicians and nurses.

Shortages of nurses have affected the availability of federal funds for nursing education. Federal funding for the training of health care personnel began with the passage of the Social Security Act of 1935. Nursing shortages in the 1950s led to funding of associate and practical nursing programs. The Nurse Training Act of 1964 provided funds to build nursing schools and for scholarships and loans for students. The Social Security Act was amended in 1977 to allow for direct reimbursement for nurse practitioners and nurse midwives in rural health care clinics. The Omnibus Budget Reconciliation Act of 1980 extended reimbursement to nurse midwives caring for the needy.

Nursing, a predominantly female profession, has historically exerted little power in the health care arena. Nurses have historically practiced more independently in the public health arena than in hospitals. The feminist movement beginning in the 1960s coincided with the evolution of advanced practice nursing. Nurses have gradually assumed more responsibility within an expanded health care system and have advocated for society’s most vulnerable members: the elderly, the impoverished, the homeless, and those with HIV/AIDS.

Nursing has been integral in several modern health movements. For example, the Surgeon General’s Healthy People Initiatives of 1979 set five health goals for the United States?the Healthy People 2000 goals. These goals have been updated and are currently known as the Healthy People 2010 goals. The Healthy People Initiative fits the emphasis of nursing on holistic wellness. Additionally, nurses have been involved in the delivery of several alternative methods of health care in collaboration with other health professions and in innovative health care settings. Nurses work with other health professionals to improve care and control costs. Nursing has also participated in the development of evidence-based practice for care, in which standards of care are based on the most current scientific evidence. Nursing is currently recognized as an autonomous profession, participating fully in the health care arena.