advanced nursing practice

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M.Sc. Nursing 1

st

year Student

Specialty: - Psychiatric

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SYLLABUS OF ADVANCED NURSING PRACTICE

Theory 150 Hours. Practical 200 Hours. Total: 350 Hours. Course Description:

The course is designed to develop an understanding of concepts and constructs of theoretical basis of advance nursing practice and critically analyze different theories of nursing and other disciplines.

Objectives:

At the end of the course the students will be able to:

1. Appreciate and analyze the development of nursing as a profession.

2. Describe ethical, legal, political and economic aspects of health care delivery and nursing practice.

3. Explain bio- psycho- social dynamics of health, life style and health care delivery system.

4. Discuss concepts, principles, theories, models, approaches relevant to nursing and their application.

5. Describe scope of nursing practice.

6. Provide holistic and competent nursing care following nursing process approach. 7. Identify latest trends in nursing and the basis of advance nursing practice.

8. Perform extended and expanded role of nurse. 9. Describe alternative modalities of nursing care. 10. Describe the concept of quality control in nursing. 11. Identify the scope of nursing research.

12. Use computer in patient care delivery system and nursing practice.

3 Course Content:

Unit Hours Content

I 10 Nursing as a Profession:

� History of development of nursing profession, characteristics, criteria of the profession, perspective of nursing profession-national, global � Code of ethics(INC), code of professional conduct(INC), autonomy and accountability, assertiveness, visibility of nurses, legal considerations,

� Role of regulatory bodies.

� Professional organizations and unions-self defense, individual and collective bargaining.

� Educational preparations, continuing education, career opportunities, professional advancement & role and scope of nursing education. � Role of research, leadership and management.

� Quality assurance in nursing (INC). � Futuristic nursing.

II 5 Health care delivery:

� Health care environment, economics, constraints, planning process, policies, political process vis a vis nursing profession.

� Health care delivery system- national, state, district and local level. � Major stakeholders in the health care system-Government, non-govt, Industry and other professionals.

� Patterns of nursing care delivery in India.

� Health care delivery concerns, national health and family welfare programs, inter-sectoral coordination, role of non-governmental agencies.

� Information, education and communication (IEC). � Tele-medicine.

III 10 Genetics:

� Review of cellular division, mutation and law of inheritance, human genome project, The Genomic era.

� Basic concepts of Genes, Chromosomes & DNA. � Approaches to common genetic disorders.

� Genetic testing – basis of genetic diagnosis, Pre symptomatic and predisposition testing, Prenatal diagnosis & screening, Ethical, legal & psychosocial issues in genetic testing.

� Genetic counseling.

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Unit Hours Content

IV 10 Epidemiology:

� Scope, epidemiological approach and methods, � Morbidity, mortality,

� Concepts of causation of diseases and their screening,

� Application of epidemiology in health care delivery, Health surveillance and health informatics.

� Role of nurse.

V 20 Bio-Psycho social pathology:

� Path physiology and Psychodynamics of disease causation.

� Life processes, homeostatic mechanism, biological and psycho-social dynamics in causation of disease, life style.

� Common problems: Oxygen insufficiency, fluid and electrolyte imbalance, nutritional problems, hemorrhage] and shock, altered body temperature, unconsciousness, sleep pattern and its disturbances, pain, sensory deprivation.

� Treatment aspects: pharmacological and pre- post operative care aspects,

� Cardio pulmonary resuscitation. � End of life Care.

� Infection prevention (including HIV) and standard safety measures, bio-medical waste management.

� Role of nurse- Evidence based nursing practice; Best practices. � Innovations in nursing.

VI 20 Philosophy and Theories of Nursing: � Values, Conceptual models, approaches.

� Nursing theories: Nightingale‘s, Hendersons‘s, Roger‘s, Peplau‘s, Abdella‘s, Lewine‘s, Orem‘s, Johnson‘s, King‘s, Neuman‘s, Roy‘s, Watson parsce, etc and their applications,

� Health belief models, communication and management, etc. � Concept of Self health.

� Evidence based practice model. VII 10 Nursing process approach:

� Health Assessment- illness status of patients/clients (Individuals, family, community), Identification of healthillnes problems, health behaviors, signs and symptoms of clients.

� Methods of collection, analysis and utilization of data relevant to nursing process.

� Formulation of nursing care plans, health goals, Implementation, modification and evaluation of care.

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Unit Hours Content

VIII 30 Psychological aspects and Human relations:

� Human behavior, Life processes & growth and development, personality development, defense mechanisms,

� Communication, interpersonal relationships, individual and group, group dynamics, and organizational behavior,

� Basic human need, Growth and development, (Conception through preschool, School age through adolescence, Young & middle adult, and Older adult).

� Sexuality and sexual health.

� Stress and adaptation, crisis and its intervention, � Coping with loss, death and grieving,

� Principles and techniques of Counseling. IX 10 Nursing practice:

� Framework, scope and trends.

� Alternative modalities of care, alternative systems of health and complimentary therapies.

� Extended and expanded role of the nurse, in promotive, preventive, curative and restorative health care delivery system in community and institutions.

� Health promotion and primary health care.

� Independent practice issues, - Independent nurse midwifery practitioner.

� Collaboration issues and models-within and outside nursing. � Models of Prevention,

� Family nursing, Home nursing,

� Gender sensitive issues and women empowerment. � Disaster nursing.

� Geriatric considerations in nursing.

� Evidence based nursing practice- Best practices � Trans-cultural nursing.

X 25 Computer applications for patient care delivery system and nursing practice:

� Use of computers in teaching, learning, research and nursing practice. � Windows, MS office: Word, Excel, Power Point,

� Internet, literature search, � Statistical packages,

6 Practical:

Clinical posting in the following areas:-

 Specialty area- in-patient unit - 2 weeks

 Community health center/PHC - 2 weeks

 Emergency/ICU - 2 weeks Activities:

 Prepare Case studies with nursing process approach and theoretical basis.

 Presentation of comparative picture of theories.

 Family case- work using model of prevention.

 Annotated bibliography.

 Report of field visits (5). Methods of Teaching:

 Lecture cum discussion.

 Seminar.

 Panel discussion.

 Debate.

 Case Presentations.

 Exposure to scientific conferences.

 Field visits. Methods of evaluation:  Tests.  Presentation.  Seminar.  Written assignments.

Advance nursing Procedures:

 Definition, Indication and nursing implications;

CPR, TPN, Hemodynamic monitoring, Endotrcheal intubation, Tracheotomy, mechanical ventilation, Pacemaker, Hemodialysis, Peritoneal dialysis, LP, BT Pleural and abdominal parecentasis OT Techniques, Health assessment, Triage, Pulse oxymetry.

Internal Assessment:

Techniques Weight age Test- (2 tests) 50 Assignment 25 Seminar/presentation 25 --- 100 ---

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SYLLABUS

Unit Hours Content

I 10 Nursing as a Profession:

� History of development of nursing profession, characteristics, criteria of the profession, perspective of nursing profession-national, global � Code of ethics(INC), code of professional conduct(INC), autonomy and accountability, assertiveness, visibility of nurses, legal considerations,

� Role of regulatory bodies.

� Professional organizations and unions-self defense, individual and collective bargaining.

� Educational preparations, continuing education, career opportunities, professional advancement & role and scope of nursing education.

� Role of research, leadership and management. � Quality assurance in nursing (INC).

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

HISTORY OF DEVELOPMENT OF NURSING

PROFESSION

Introduction:

Knowledge of the profession‘s history increases the nurse‘s awareness and promotes an understanding of the social and intellectual origins of the discipline. From its earliest history nursing was a form of community service to protect and preserve the family. Historically men and women held the role of nurse. In Prehistoric Period, women were responsible for gathering herbs, roots and plants that were used to heal the sick.

History of nursing:

Christianity: The entry of women into nursing can be traced to approximately 300 AD. Christians taught that men and women are equal before God and appealed to carry on His work in the behalf of all who were in distress. The founding of Benedictine Order in sixth century increased the number of men in nursing.

Middle Ages: During the middle Ages (1100-1200 AD) charitable institutions were started to care for the aged, sick and poor. Nurses delivered custodial care and depended on physicians or priests for direction. Nurse Midwifery flourished during middle ages. Fifteenth To Nineteenth Century: The Crusades expanded health care by establishing hospitals and nursing orders for men. Christianity greatly influenced the development of nursing. One of the earliest records of Christian nursing was the formation of the order of Deaconesses, a group of public health or visiting nurses. Deaconesses‘ appointments by the bishops were highly valued and given only to women of high social standing. The need for nurses and increasing nursing responsibilities were due to the economic growth of eighteenth century, the smallpox epidemics and the Revolutionary War.

The Sisters of Charity, founded in 1633 by St. Vincet de Paul, cared for people in hospitals, asylums and poor houses. The sisters became widely known as visiting nurses because they cared for sick people in their homes. The first Supervisor of the Sisters of Charity was Louise de Gras and was later known as Sr. Louise de Marillac. She established perhaps the first educational program to be associated with a nursing order. In 1809 the Sisters of Charity was introduced in America by Mother Elizabeth Senton, later their name was changed to Daughters of Charity.

In the eighteenth century the further growth of cities brought an increase in the number of hospitals and expanded role of nurses. Smallpox epidemics in the French Colonies and during the Revolutionary war the English colonies increased the need of nursing services. Because there was little formal nursing education, nursing knowledge and skills were generally passed by experienced nurses.

During the nineteenth century Protestant churches revived the Deaconess Order. The Deaconess Institute at Kaiserwerth, Germany was established in 1836 by Pastor Theodore Flieder.

Florence Nightingale: The founder of modern nursing, Florence Nightingale, established the first nursing philosophy based on health maintenance and restoration in Notes of Nursing: What it is and what it is not. Her views on nursing were derived from

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a spiritual philosophy, developed in her adolescence and adulthood and reflecting the changing needs of society.

In 1853 Nightingale went to Paris to study with the Sisters of Charity and was appointed superintendent of The English General Hospitals in Turkey. During this Crimean War period she brought about major reforms in hygiene, sanitation and nursing practice and reduced the mortality rate at the Barracks Hospital, Turkey.

The Civil War: The civil war stimulated the growth of nursing in United States. Clara Barton, founder of American Red Cross, tended soldiers on the battle field, cleansing the wounds, meeting their basic needs and comforting them in death. Dorothea Leynde Dix, Mary Ann Ball and Harriet Tubman also influenced nursing during Civil War. After the Civil War, nursing schools in the United States and Canada began to pattern their curricula after the Nightingale School. St. Catherine‘s in Ontario, was founded in 1874.The first African-American professional nurse was Mary Mahoney. Isabel Hampton Robb, a graduate of St. Catherine‘s in Ontario was the first superintendent of Johns Hopkins training school in Baltimore, Maryland in 1894.Nursing in hospitals expanded in the late nineteenth century. However, nursing in the community did not increase significantly until 1893, when Lillian Wald and Mary Brewster opened the Henry Street Settlement which focused on the health needs of poor people who lived in the tent aments in New York City. Wald described her activities with the Henry Settlement in the textbooks The House on Henry Street and Windows on Henry Street.

Twentieth Century: In the early twentieth century, a movement toward a scientific, research-based defined body of nursing knowledge and practice was seen. Nurses began to assume expanded and advance practice roles. Mary Adelaide Nutting, a member of the first graduating class at Johns Hopkins Hospital and successor to Isabel Hampton Robb as superintendent of the Johns Hopkins Training School, was instrumental in the affiliation of nurse‘s education with university. She became the first professor of nursing at Columbia University Teachers College in 1907.

In 1923 the Rockfeller foundation funded a survey of nursing education, The Goldmark Report. The report concluded that the nursing education needed

Increased financial support and suggested that the money be given to university schools of nursing.

As education developed, nursing practice also expanded. In 1901 the Army Nurse Corps was established. By the year 1908 Navy Corps established. By the year 1920s nursing specialization was developing. Graduate nurse midwifery programs were initiated and beginning in 1950s specialty nursing organizations such as Association of Operating Room Nurses (1949), American Association of Critical Care Nurses and Oncology Nursing Society were formed.

Today, the profession is faced with multiple challenges. Nurses and Nurse Educators are revising nursing practice and curricula to meeting the ever changing needs of society.

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CHARACTERISTICS OF PROFESSION

Although nursing has been called a profession for many years, an assessment of characteristics of a profession indicates that it should more accurately be considered as ―emerging profession‖. Characteristics of a profession have been defined as:

 Authority to control its own work.

 Exclusive body of specialized knowledge.

 Extensive period of formal training.

 Specialized competence.

 Control over work performance.

 Service to society.

 Self-regulation.

 Credentialing system to certify competence.

 Legal reinforcement of professional standards.

 Ethical practice.

 Creation of a collegial subculture.

 Intrinsic rewards.

 Public acceptance.

Apart from this the characteristics of a profession can be categorized as following:

Intellectual: This character is reflecting commitment to serve society. This category has three components:

a) Body of knowledge: professional practice is based on body of knowledge derived from experience (leading to expertise) and research (leading to theoretical foundation for knowledge).This knowledge base contributes to judgment and rationale for modifying actions according to specific situation. However, the education has often emphasized proven methods for responding to particular kinds of situations e.g. clients may be discharged without self care teaching because the doctor did not write an order.

b) Specialized education: Nursing transmits knowledge through specialized education. However, there are five levels of basic education for registered nurses, all of which prepare for one licensure examination. Three of five levels (diploma, associate degree and baccalaureate degree) accept high school graduation where as other two (master‘s degree and doctoral degree) accept college with liberal arts majors.

c) Critical and Creative Thinking: A logical and critical thinking process is one essential component of professional practice. The nursing process is a problem solving approach. It includes:

 Collect and organize information derived from multiple sources.

 Decide what is needed, based on that information.

 Select and implement one approach from among many possible approaches.

 Evaluate the results of the process.

Personal: This category emphasizes on autonomy. Autonomy means the practitioners have control over their own functions in a work setting. Autonomy involves independence, a willingness to take risks and responsibility and accountability for one‘s

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own actions as well as self-determination and self-regulation. The autonomous practitioners are also obligated to collaborate with others for the benefit of the patient. Interpersonal: Nursing is a significant therapeutic interpersonal process. It functions cooperatively with other human processes that make health possible for individuals in the communities. The nurse collaborates with the patient, significant others and health care providers in the formulation of overall goals and plan of care and in the decisions related to care and delivery of services.

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CRITERIA OF PROFESSION

Bixler and Bixler Criteria for Profession:

Genevieve and Roy Bixler who were against the status of ‗Nursing as a Profession 1945, appraised nursing according to their original seven criteria as follows:-

1. A profession utilizes in its practice a well defined and well organized body of knowledge, which is on the intellectual level of the higher training.

2. A profession constantly enlarges the body of knowledge its uses and improves its techniques of education and service by the use of the scientific method.

3. A profession entrusts the education of its practitioners to institutions of higher education.

4. A profession applies its body of knowledge in practical service, which is vital to human beings and social welfare.

5. A profession functions autonomously in the formulation of professional policy and in control of professional activities there by.

6. A profession attracts individuals of intellectual and personal qualities who exalt service above personal gain and who can recognize their chosen profession as life long. 7. A profession strives to compensate its practitioners by providing freedom of action, opportunity for continuous professional growth and economic security.

After examining all the criteria of profession and other related concepts and aspects ―world health organization‖ has already recognized ‗Nursing as a Profession‘.

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PRESPECTIVE OF NURSING PROFESSION:

At National Level: During the Post Independence period there has been enormous change and development in the field of medicine, medical technology, health care and nursing. Some vital recommendations to the Bohre Committee relevant to nursing profession are given below:

1. Stipends to the nursing students: In order to prevent economic barriers in the way of suitable persons entering the nursing profession, the committee suggested the provision of Rs.60 per month for pupil nurses.

2.Nurses, Midwives and Dais: The committee suggested that by 1971, the number of trained nurses available in country should be raised to 7, 40,000. As essential step towards the achievement of this objective was the removal of the existing unsatisfactory conditions of training and service. The committee made proposals to improve the situations.

3. Training of Nurses and Midwives: In view of the extreme shortage of nursing personnel the committee recommended that the first group of 100 training centers, each taking 50 pupils, should be started two years before the Health Organization began to be established, that another set of 100 training centers should be created during the first two

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years of the schemes and that a third group of the same number of training centers should be established before the third year of the second puperium.

4. Male Nurses: Male nurses should be trained and employed in large numbers in the Male wards and Male Out Patient Departments of Public hospitals, thus releasing women workers for other work.

5.Public Health Nurses: The committee also made specific proposals with regard to the training of Public Health Nurses. These should be fully qualified nurses with training in midwifery as well.

6.Midwives: The number of midwives actually available for midwifery duties in the country was probably 5000.The committee laid down certain fundamental requirements which should be met before an institution could be organized as a training centre for Midwives.

7.Dais: The continued employment of women as dais was inevitable. The committee advocated the training of dais as an in trim measure until an adequate number of midwives would become available.

8.Nursing Staff: The report recommended to produce another category of Nursing Health Personnel called Auxiliary Personnel. Auxiliary Nurse Midwife training was started to meet the health needs of the country.

Establishment of Indian Nursing Council: As a result of Bohre Committee recommendations, Indian Nursing Council was established in 1947 to regulate the standards of Nursing Education. Nursing Council made three important decisions:

a) There should be only two standards of training of General Nursing and Midwifery: i. The full course of General nursing to be for three years followed by a minimum of nine months of midwifery.

ii. A course of Auxiliary Nurse Midwife for two years.

b) The minimum entrance requirement of General Nursing Course to be Matriculation and for Auxiliary Nurse Midwife to be 7th or 8th standard of education.

c) The Auxiliary Nurse Midwife Course to replace various courses like Junior Grade Nursing Certificate and courses other than for nurses.

Development of nursing education in India:

The Auxiliary Nurse Midwife/ General Nurse Midwife Programmed:

a) The Indian Nursing Council at its meeting in 1950 came out with some important decisions relating to future patterns of Nursing Training in India. One of the important decision was that there should be two standards of training of Nursing and Midwifery:

 A full course of 3 yrs in Nursing and minimum of 6 months of Midwifery.

 A course of Auxiliary Nurse Midwives of 2 yrs which would replace various courses for Junior Grade Certificate.

The first course of A.N.M was started at St.Mary‘s Hospital Taran Taran, Punjab in 1951.Initially a very few training centers undertook to give this course but the financial aid was given by Govt. Of India under the scheme for preparing personnel for Primary Health Centers gave a great impetus to the training program. The entrance qualification was raised from 7th class passed to matriculation.

UNIVERSITY LEVEL PROGRAMMES:

Basic B.Sc. Nursing: The need for providing basic training in nursing at University Level was felt by the members of TNAI from 1940 onwards. B.Sc. Nursing (Hones.) was

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started at Delhi in July 1946 in School Of Hospital Administration which was started in 1943.This school was renamed as College Of Nursing which is now called Rajkumari Amrit Kaur College OF Nursing in1972.This college is located at Lajpat Nagar, New Delhi. A similar course in B.Sc. Nursing was started at CMC Vellore, Madras University, and Tamil Nadu in 1946 by the Joint Church Society of England, U.S.A and Canada. Post Basic/ Post Certificate B.Sc. Nursing: The need for higher training for certificate nurses was also stressed by the Mudaliar Committee in 1962.For up gradation of professional standard, two year Post Basic Certificate B.Sc. Degree Programmed for nurses with Diploma in General nursing and Midwifery was started in Dec.1962 by the School of Nursing, University of Thiruvananthpuram.

POST-GRADUATION EDUCATION:

M.Sc. Nursing Education: Two year course in Master of Nursing was started at Rajkumari Amrit Kaur College of Nursing, New Delhi in 1959.In 1969; M.SC Nursing was started at CMC Vellore affiliated to Madras University. The M.Sc. Nursing Curriculum was prepared and prescribed by Indian Nursing Council in 1986 which is implemented by all the colleges. M.Sc. in Psychiatric Nursing was also started in Sept. 1983 at NIMHANS, Bangalore. This college is affiliated to Bangalore University.

M. Phil Programmed: The inspection committee constituted by INC under statute 30(4) for the inspection of the college, visited RAK College of Nursing, New Delhi on September 13, 1977 and advised the principal to form an M. Phil committee to assess all the requirements for the said Programmed. But due o some administrative reasons the M. Phil Programmed could be started only on Oct.15, 1986 after due approval of the M. Phil Committee members. The Programmed is of 1 yr for regular candidates and 2 yr for part time candidates.

Ph. D Programmed: Ph. D Programmed was started in few colleges of nursing like College of Nursing PGI, College Of Nursing CMC Vellore, and College Of Nursing Affiliated to Mangalore University and at RAK College of Nursing, Delhi University etc. from 1990 onwards. Ph. D Programmed in Psychiatric Nursing is also there in NIMHANS, Bangalore, for their own faculty.

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AT GLOBAL LEVEL:

Introduction:

There are various educational routes for becoming a Professional Registered Nurse. Initially hospital Schools of nursing were developed to educate nurses to work within those institutions.

Associate Degree Education: The associate degree program in the United States is a 2 yr program that is usually offered by a University or Junior College. This program focuses on the basic sciences, theoretical and clinical courses related to the practice of nursing. Diploma Education: The diploma program in the United States is a 2-3 yr hospital based program. Diploma programs focus on the basic sciences and on theoretical and clinical courses related to nursing practice, usually with a substantial clinical component. In U.S, diploma programs are declining in numbers. In Canada, diploma programs are offered in community colleges or hospitals and are 2 yr programs.

Baccalaureate Education: The baccalaureate degree program usually encompasses 4 yr of study in a college or university. The program focuses on basic sciences and on theoretical and clinical courses, as well as courses in social sciences, arts and humanities

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to support nursing theory. In Canada, the degree of Bachelor of sciences in Nursing (B.Sc. nursing) or Bachelor in Nursing (BN) is equivalent to the degree of Bachelor of Sciences in Nursing (BSN) in the United States. RN completion programs are available at many colleges and universities. These programs are designed to assist the practicing RN in obtaining a baccalaureate degree in Nursing.

Accreditation: To be accredited, nursing programs must meet certain criteria established by the National League for Nursing Accrediting (NLNAC).This voluntary accreditation is available for basic nursing education programs and masters degree programs in nursing.

Licensure: In the U.S, RN candidates must pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN), which is administered by the individual State Board of Nursing. Regardless of educational preparation, the examination for RN licensure is exactly the same in every state in United States.

Certification: Beyond the NELEX-RN, National Nursing Organizations such as ANA, have many types of certification that the nurse can work toward. After passing the initial examination, the nurse maintains certification by ongoing continuing education and clinical or administrative practice.

Masters Degree Preparation: A person completing a graduate program can receive the degree of Masters in Arts (MA) in Nursing or Masters in Science in Nursing. This provides the advanced clinician with strong skills in nursing sciences and research based clinical practice. A Masters degree in nursing can be valuable for nurses seeking roles of nursing educator, clinical nurse specialist, nurse administrator or nurse practitioners. Doctoral Preparation: The first nursing doctorate program was opened in 1953 at University of Pittsburgh. Other programs emphasized on basic research and theory and award the degree of Doctor Of philosophy (Ph. D).

Continuing and In-service Education: Continuing education involves formal, organized and educational programs preferred by state Nurses Associations and Educational and Health Care Institutions. Other goals include helping nurses become specialized in a particular area of practice and teaching nurses new skills and techniques. Licensed Practical Nurse Education: A licensed practical or vocational nurse is trained in basic nursing techniques and direct client care. The Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) practices under the supervision of a Registered Nurse (RN) in a hospital or community health practice setting.

16 BIBLIOGRAPHY:

1.Basavanthappa B.T ‗Nursing Administration‘ Ed 3rd Published By Jaypee Publishers pp-1-17.

2.‗History and Trends in Nursing in India‘ Published By Trained Nurses Association of India pp-1-22.

3.Kay Kittrell Chitty ‗Professional Nursing Concepts and Challenges‘ Ed 4th Published by Elsevier Saunders pp-2-27.

4. Leddy Susen and Pepper J. Mac ‗Conceptual Bases Of Professional Nursing‘ Ed 4th Published By Lippincott pp-4-11.

5.Potter and Perry ‗Fundamentals of Nursing‘ Ed 5th Vol. 1st Published By Mosby Harcourt India pp-376-380.

6. Sorensen and Luckman‘s ‗basic Nursing: a psycho physiological Approach‘ Ed 3rd Published by W.B Saunders pp-6-18.

7. ‗The Foundations of Nursing‘ Vol. 1st Published by B.I Publications Pvt. Ltd. pp-45-71.

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 DEVELOPMENT OF NURSING PRACTICE

Int roduction:

Nursing is a unique profession. It is in its simpler form existed from the beginning of human life and is essential to the maintenance of life. The first mother was the first nurse. From the time of the first mother down to the present day, we have found women protecting their children, and taking care of the elderly and sick members of the family. They also rendered their services to the neighbors during illness. Simple procedures for the sick were adopted, e.g., application of cold water over the forehead, to reduce fever, application of pressure over a bleeding injury. Individuals who possessed special gifts and aptitudes for caring and healing gradually collected a lot of healing knowledge through trial and error, and passed on from generation to generation.

The word nursing comes from the Latin word ―Nutrix‖ meaning of ―Nourish or cherish‖. The word nourishes means to supply that which is necessary to life. When nursing perceived as a science, the term nursing becomes a noun signifying a body of abstract knowledge.

Nursing is a fast developing profession. To attain this stage it has taken a longer time. In early days only orphan, widows and nuns took up this nursing, professional nursing is adopting to meet changing health needs and expectations.

Nurses now receive advanced education in such specialties as intensive care, coronary care, respiratory care, ontological care, neonatal intensive care, renal dialysis care, trauma care, transplant care and other to fulfill the needs and expectation in contemporary period.

For the development of the nursing profession in new era one must know the philosophy, goals, and development of nursing for the betterment of the profession.

Historical development in nursing:

Historical background is an important aspect of every discipline. The nursing history is not just the story of dates, conquests, discoveries or research in the field of nursing but it provides the basis for understanding the nursing today. Just as childhood shapes to adult hood, nursling‘s origins and development shape it‘s response to the present.

Development of nursing helps us:

-To understand and interpret the changes which have taken place in nursing.

-To understand some of the problems of the past and how they have been solved.The study about those who have developed nursing to the present stage will stimulate the present generation.

It helps to accept the share of responsibility for the future of nursing.

Nursing has a fascinating history that parallels the history of human kind. For as long as there has been life so has there been the need to seek care and conform from illness and injury. From the dawn of civilization, evidence prevails to support the premise that nursing has been essential for the preservation of life. Survival of the human race, therefore, is inextricably intertwined with the development of nursing.

Genesis of nursing:

History of nursing as an episode in the history of women. The nurse is the mirror in which reflected the position of women through the ages‖. During that time women restricted to home. Nursing has its origins in the mother. Care of helpless influence and must have co existed with this type of case from earliest times.

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As the evolution taken place in the world another diminution was added to its meaning women who cases for and tends young children particularly with respect to the training, training and general upbringing of the young. The word nurse maid and governess thus reargued and became titles for the young girls.

Stewart and Austin hesitated 2 kinds of helpers: Born Nurses: The women of their maternal instincts.

Child Nurses: With the teaching and training of children so nurse became more closely associated the healing arts. Time progressed love and caring along were not sufficient to nature health or overcome disease. The development of nursing thus developed on the additional essential ingredients, such as SKILL EXPERTNESS AND KNOWLEDGE: Male and females have a tendency to respond to helplessness. Threat to life, disease and injury. So they functioned as nurses. The role of nurse gradually enlarged with much broad scope for care of sick. The aged, the helpless and the handicapped as health promotion of vital components of nursing.

The head, heart and the hand become truly the strong foundation for modern day nursing. Nursing: the seed of early community service:

This service was related to preservation and protection of the tribe and its members during this period community was influenced by waves of religious awakening ideas of chivalry. Patriotism and democracy social and humanitarian efforts. As more civilization developed the nursing care extended to poor people, prevention of disease.

For longer period Nursing could be done only by those who renounced the world. Religious motive, self scarification provides an excellent qualification for assuming the Nursing role.

Because of continued civilization all tribes followed some type of sanitary practice. Elementary practices become more sophisticated as technical advances. Such as improvement in water drainage system, disease and communicability that is over all emphasis on health. During these period medicine men, priests, wise women and midwives serve to the community as well as to the individual. The basic concept that included in nursing is health and illness. Thus the early roots of public health become a prominent aspect of the nursing role.

Care of the sick among primitive people:

No records of nursing in the prehistoric times what we know about the nurse of the sick in primitive times has been discovered through myths, songs, and the findings at archaeologists.

Primitive man was much closer to nature and animals. The first trace of parental love, tendons and natural aid were elicited by birds and other animals. They were nature worshippers. This belief is known as ―animism and the period as called as Stone Age or age of hunters‖. He believed that thing in nature like a tree or river had a sprit or soul. Water and trees were friends while storms and poisonous plants were enemies. Natural colonies were attributed to the anger of god.

Beliefs: The primitive people believed that sickness comes due to the following reasons: 1. Anger of the offended gods, devils and evil spirits.

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4. Bodily invasion by a sprit to get rid of evil spirits dwelling in the body, the body had to be made unpleasant for them.

5. Loss of soul - A soul catching ceremony was required for its return.

6. Dreams – It was believed that soul leaves the body during the period of dreaming. Preventive measure and treatment:

 Starving, beating, loud noises, magic treatise and ceremonies and sudden fright were also tried.

 Starting the evil spirit with a frightening mask and deafening noises.  Using noxious body.

 Giving noxious medicines.  Trephening the skull with stone.

 White magic was used to attract good or helpful spirits. While black magic was used to drive away evil spirits or bring harm to one‘s enemies.\

 Hot and cold baths.  Faith of the person.

 The above treatment was done by medicine man or priest physician. The heritage of nursing, initial image of the nurse:

 The role of the Nurse is mother.

 The concept of Nursing as a feminine occupation

 Nursing started to keep healthy full environment and keep the people healthy, and to provide comfort care and assurance to the sick.

 They were capable, concerned and compassionate persons whose practice encompassed ―a wellness‖ in addition to an illness component.

 They used problem solving skills as well as intuition in assessment of human needs.  They developed body knowledge and utilized intellectual interpersonal and psychomotor skills in meeting human needs.

 They shared their knowledge and skills beyond family and neighborhood bonds by teaching individuals, families, communities and their own successors.

 They possessed a role and function separately and distinct from those of medical practitioners.

Role of the nurse in the care of the sick:

From the time of the first mother down to the present time we find women protecting and caring for their children aged and the sick members of the family. Traditionally female role is wife, mother, daughter, sister have family members thus nursing could be said to have its roots in the home. Nursing role has always entailed humanistic caring, comforting and supporting, nourishing, cleaning aspect to the patient. Knowledge of these simple skills was passed down from generation to generation, tenderness, concerns, love and hope practices in nursing evolved.

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BEGINNING OF CIVILIZATION 5000 BC TO 1 AD:

Definition: Civilization is the product of our higher qualities as exercised first by original and superior individual and then accepted or followed by a sufficient numbers of human beings to make it a social fact.

Prof. Lyna Theorndike. Medicine and nursing in early civilization:

The new Stone Age period: Egypt:

The oldest medical records have come from Egypt date back to 1600 BC – 3000 BC - Writing was introduced first.

4000 BC – Produced a calendar of 12 months with 30 day. - 5 days to celebrate the birth of God.

5000 BC – man improved to built the houses, pyramids Invented axe and grow own crops.

The priest physician was the greatest of all priests. He is called as ―IMHOTEP‖ means the cometh in peace. Temples were used as halls of healing health. At the time ―animism‖ replaced by ―mythology‖ they believe life after death. They worshiped Isis, Mother earth who helped the sick most frequently through the dreams.

Temples become centers of community and national life. Persons who were ill were bought to the temple, left there over night to seek the priestly intercession of the gods. The priests were helped by one group of temple women who were of high social positions and held the rank of priestess. They are believed to perform some nursing duties.

―Eber Papyrus‖ is known as the oldest complete medical book in the world. Contains a classification and description of disease and surgery.

Berlin Papyrus – focused on the treatment of disease of the anus.

Hygienic principle followed by the Egyptian especially cleanliness of body and dress. They practiced circumcision. They recognized the importance of an adequate system of drainage, good water supply and also the inspection of slaughter house.

Nurses role:

Women in Egypt had no career but had some freedom the mother had a position of authority. Mother and daughter probably nursed the sick in their homes.

Journal reference:

Nursing times. January 21 volume 94 page no 34 to 36

Kante (Balck Smith) Soknolonba they come from the caste that makes knives, tools and weapons. Female circumcision is family tradition. Here removal of labia and vaginal orifice is reduced. She can excise 40 girls per day with out any problem. Excised from babies to 20 yrs olds using alcohol as antibiotic and paste of leaves and takes about a month to heal. They do it because they consider it is a form of purification and rite of passage to women hood. Ancient Egypt people were organizing probably some people believe that women who have not been excised will eventually not be able to have intercourse or become pregnant. Because the clitoris will grow until it obstruct the orifice.

21 Babylonian (Iraq):

Began as early as 4000 to 3000 BC the first Babylonian empire was founded by king ―Hamurabi‖. He developed a code of laws for the whole empire. Enclosed the treatment of the diseased people from poor and defenseless class. Punishment for doctors was severe, if patient died. E.g., Doctors hands were cut off, Nurse were treated as slaves Health beliefs and treatment:

They believed that illness was due to 1. Sin and displeasure of the God 2. Punishment from sinning Principle mehtod of treatment:

1. Ridding the human body of the demons of disease by incantations. 2. Application of herbs.

The nurse carried out the care and treatment as directed by the physician. Palestine (israles):

 The practice of hygienic and health rules were given by Moses.  The hospitably and visiting the sick was considers as their duty. Some of the health rules were‖

 Inspection and selection of food what to eat and what not to eat.  Disposal of excreta by burial with enough sand.

 Disinfecting and purification.  Hygiene of women after child birth.

 Reporting and isolating communicable disease.  Quarantine.

 Circumcision as a religious practice and as a sanitary measure.

Hebrew nurses had a high position and participated care full in planned programmed of visiting the sick at their homes.

Persia (iran):

Both Persians and Hebrews had religious law and practices regarding physical health, ―Zend-Avesta was written by ―Zoroaster‖ who lived about 600 B.C. Fire, earth, and water were considered as sacred elements and among those fire purest.

Health beliefs and treatment:

Illness is due to evil spirit and they had three types of practitioners they were, 1. Those who treat with knife and heal. Called as Surgeons.

2. Those who treat with herbs and heal.

3. Those who treat with prayer and holy words and heal. Hebrews:

Many rules and regulations in regard to social and religious custom and health sanitary practices are compiled into what is called the mosai code. This code presents a systematic organized method of prevention of disease it includes principle of personal hygiene relating to rest, sleep, and cleanliness. Hours of work and special rules for women, midwifery principles of public hygiene and signification regarding food, disposal of excreta, garbage, and isolation quarantine disinfecting and reporting of communicable diseases. The high priest was priest physician and health inspector. They practice excellent hospital, visiting and caring for the sick were a religious duty.

22 NURSING:

Ancient Hebrew nurses had a high position and participated careful in planned programmed of visiting the sick at their homes and caring for them. The Hebrew nurses were active in promoting and maintaining physical, mental and community health and they continued their services in health maintenance and health education.

Ancient Americans:

In the North and South America the culture was highly developed before Columbus found the new continent there were several group of people as the Mayas, Incas, and Aztecs.

 Mayas – Practiced human sacrifices to care illness.

 Ideas and Aztecs were skilled engineers and built roads and suspension bridges. They believed that disease is caused and by the displeasure of the Gods. Disease were prevalent and treated with bloodletting, cupping or sucking, massaging, sweating, splinting, setting of bones, tooth extraction, amputation, suturing and bandages.

Greece:

They believed medicine was of divine origin and was represented by many God. They worshipped ―Apollo‖ as god of the sun. He was regarded as the God of Healing.

The unclean such as the dying and obstetrical patients were not allowed to come in or to remain in the temple. It was not until after 170 A.D. To the Greeks, hospitality was a virtue and a religious duty. So they met this by providing organized charity and cared for the poor and sick. They considered death and birth as sources of pollution. Greeks built great sanctuaries for healing the sick and for incubation. This period ―Attendants‖ served the sick. Along with the priest and physician.

The era of scientific medicine and perhaps nursing begins with ―Hypocrites‖. He was born in ―Cosine‖ in 460 BC. He was the son of a priest physician

At this time ―Hippocrates‖ laid the foundation for the science of biology as well as the study of comparative anatomy. He believed that disease was due to man‘s disobedience to the laws of nature and not due to evil sprit. Since he led the scientific way of practice, he is known as the ―Father of Scientific Medicine‖

His method of treatment was based on four principles.  Observe all symptoms.

 Study the patient.  Evaluate honestly and.  Assist nature.

Hippocratic medical achievement can be grouped in the four major areas:-

 Rejection of all beliefs in the super natural origin of disease.  Development of through patient assessment and recording.  Establishment of the highest ethical standards in medicine.  Author of medical books.

The symbol of caduceus: 2 wings resembles speed of work

23 INDIAN:

 The earliest literature of India consists of the Sanskrit Vedas believed to have existed in 1600 BC

 Rig Veda – Disease was regarded as the result of divine wrath.

 Atharvana Veda – It deals innumerable incantations and charms for the practice of magic, disease, injuries, health and fertility.

 Ayur Veda – It deals with medicine, surgery and children disease.  The samhitas (Books) gives the details of hospitals and attendants.

 The Shushrutha, Samhita states that the physician, the patient, the medicine and attendant are the four essential facts in the care of disease.

 It describes the nurse as one who is cool headed and pleasant in her behavior.

 Nurses are very attentive to the requirements of the sick and strictly follow the instructions of the physician.

 During 500 BC to 300 AD Buddhism raised the practice of medicine rose to new lights but surgery declined.

 Pharmaceutical gardens were maintained to supply herbs and drugs.

 Large numbers of hospital were established and monastic universities were founded. Famous among them were Dhakshasela and Nalanda.

Status of women in india:

The main activities were management of the home and care of the family numbers during illness.

CHINA:

Sen. – long was known as the father of medicine they practiced vaccination physiotherapy as early as 1000 B.C. They recognized disease like syphilis, Gonorrhea, they could treat anemia with the liver in their diet and thyroid with iodine, leprosy with chaulmoogra oil.

Journal reference:

Nursing Times January 21 Volume 94 Page No.28-29

Sexually transmitted infections have a long pedigree they mentioned in Bible, ancient Chinese and Greek medicine texts. Until the 15th century the most common sexually transmit infection to be gonorrhea, which on treated can lead to infertility and various chronic conditions.

In the 15th century a new deadly sexually transmitted pestilence took Europe by storm. Syphilis is called as ―great Pox‖ syphilis emerge result of transoceanic exchange. This concept developed by the historian William H. Mc Neill, states that when societies came into contact for the first time they lack natural resistance to each other‘s infection.

Common people believed that disease was due to evil spirit and who ever touches the person the evil spirit gets into other body.

ROME:

They copied much from Greece they were idol worshippers and in later period they worshipped there emperors also. They had good system of sanitation, paved roads and bridges. Drainage system and sewers were made; drinking water was brought out by aqueducts. They had public baths for men and women and had public dispensary.

Women of Rome had certain amount of freedom, old women and men of good character did nursing.

24 CEYLON:

Ceylon adopted India‘s methods.

 There were hospitals and well prepared physicians and nurses to attend to the sick. NURSING IN EARLY CHRISTIAN ERA:

Christian Motive in Nursing:-

Christianity taught that one could give kind service to humanity without expectation of any reward. Some of the teachings of the Christ influenced the nursing. The story of god Samaritan in the bible insisted particular attention towards the sick and poor. This idea motivated nursing, medicine and charity. While the other religions believed that illness is due to fate,

Christians did not accept illness as something necessary or deserved. From the Christian teachings, the concept of altruism evolved the care of sick or disabled as a corporeal act of mercy.

 To feed the hungry.  To give water to thirsty.  To cloth the naked.  To visit the imprisoned.  To shelter the homeless.  To care for the sick.  To bury the dead.

Early Christian Ordersapostolic Orders: there were three groups of Christian women k known as apostolic orders. They were either unmarried or widows Deacons visit the homes of the poor and sick and provided food and money for the needy and prayed with them. They gave medicines and their services according to their ability and knowledge. PHOEBE:

Phoebe was a Greek lady she helped to nurse the sick in their homes. So she had been awarded the dual honor of being the world‘s first visiting nurse. And she was known as for runner of the modern public health nurse

Fabiola:

She was a very beautiful young lady who made a public confession about her sins and turned her home to a free Christian hospital. She gathered sick from the streets and nursed them.

Paula:

Paula was the friend of fabiola. She was wealthy and very intelligent.When her husband

died she joined Christianity. She and her daughter, Estonia, went to Palestine and settled in the Bethlehem. Here she built hospices (place of shelter for

travelers) and hospitals for the sick. She and her staff did the nursing. She established a monastery in Bethlehem and gathered a group of devoted women. After her death, in 404 AD her work was carried on by her daughter.

Beginning of the first century‘s church and teachings of Jesus Christ expressed concern for orphans, the poor, and travelers and above all, the sick, religious influence raised the social position of nursing. Men and women committed to church spread the philosophy of Christianity while providing nursing care to the sick. The deaconesses of the early church, widowed and unmarried lay women appointed by the bishops visited the sick

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much like modern visiting nurses. The Romans visiting nurses soon become ‗first visiting nurse‘ Phoebe (55 A.D) is the most noted deaconesses in nursing history. Fabiola established first general hospital in Rome in 330A.D. Although nursing became increasingly humanistic, there were no efforts to start a formal education or training for nurses.

Early middle age:

Early middle age is the Dark Age in the history of nursing. This era began with the fall of the mighty Roman Empire. A cording to the self needs of the time three protective units was developed.

The monasticism The feudalism The guilds.

The Monasteries became the chief place for education, medicine, and nursing. They gave medical and nursing care to travelers, poor and needy.

In feudalism the king owned all the land. He gave portions of land to his favorite subjects who were knights. The training of knight, which become known as ―chivalry‖ stressed service to others, protection and defense of the weak.

Guildes:

This was the first organization of workman. In guilds learning skill was stressed, higher standards of work encouraged and unethical practices were checked this has been fallowed in nursing.

In early middle ages nursing had developed roots, purpose and leadership.

This period is considered as dark ages in the history. The monastic orders also developed during this time. One of the earliest organizations for men in nursing the parabola, brotherhood was established during this period. Responding to the needs created by the black plague this group organized a hospital and traveled throughout Rome caring for sick. The order of Benedictine which still exists was founded during this time increased the number of men entering nursing. Such famous monastic nurses‘ St. Brigid, St. Scholastic and St. Hilda were founding schools, tending to the sick and giving to the poor. These monasteries were offering care to the sick and education to the uneducated. Augustine sisters found giving care for mentally retarded and mentally ill in the Greece was known to be oldest order of nursing sisters. In some of medieval a hospital nursing was done by dedicated women and nursing brothers. One nurse being allotted to 15 patients by day, but each night nurse was responsible for 100 patients during this stage. Late middle ages (1000 a.d-1500 a.d):

This late middle age is ‗crusades‘ (means religious war between the Muslims and Christians) for 200 years (between 1096-1291) During this, there was great need for hospitals and care givers, in 1050 some wealthy merchants of Amalfi founded two hostels in Jerusalem, and these took upon themselves a combination of warfare charitable relief and hospital nursing.

Military nursing orders were formed for the first time, soldiers were used to give care for the needy whenever they were free, and serving brothers carried on regular ward duties at all times. They gave food to pilgrims, alms to poor, and the care for the sick.

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Mendicants were traveling monks their activities was giving nursing care to the sick. They formed several nursing and religious and non religious (secular orders) for providing nursing care.

Indivisual nurse of the time:

St. Hildegard: she wrote books on medicine in which she described about jaundice, lung disease, and dysentery.

St. Elizabeth of Hungary (1207- 1231) Visited the sick in the hospitals. St. Catherine of Siena (1347- 1380)

When plague came to her town she spent day and night in giving care to patients. Queen Elizabeth of Portugal She founded a hospital for the poor and nursed the sick. Queen Osabel: introduced ten types of hospitals and ambulances for injured on battle. Queen Naslilida; founded hospitals and personally gave care.

Organization of the hospitals

Crowded living conditions and increase in the spread OF DISEASES caused the demand for more hospitals.

The first hospital in England (1036 AD) was built at York fallowed by St.Barthalomeus hospital (1123), St. Thomas hospital (1213)in London which was used many years later by Nightingale for clinical experience of nursing students. Bethlehem hospital later became first mental hospital.

Response of nursing to the needs of the society (1500 – 1850): Dark ages of nursing:

The beginning of the 16th century was marked with religious, political and industrial revolutions. As ‗Protestantism‘ sweep across the Europe, monastery hospitals were closed along with the early nursing orders affiliated to them. There was shortage of nurses to care for the sick poverty, epidemics like leprosy; typhoid and plague were critical health problems at this time. To meet this crisis, women who committed crime were recruited to serve as nurses in lieu of surviving jail sentences. Thus society viewed nurses as disreputable and the feeling of disrespect towards nurses. The working conditions of the nurses deteriorated, the pay was poor and nurses were considered as menial servants. Attempts to improve nursing and images of nurses were abandoned. Industrial revolutions resulted in physical and mental stress and unsanitary conditions. It is commonly agreed that ‗darkest period‘ in the history of nursing that is from 17th

to 19th century.During this period nurses were poorly fed, over worked and badly treated only those who could find nothing else to do did nursing. Nurses were lacking in skills and morals. The beds were large and many patients were put together there was no segregation or isolation. In those days doctor did most of the work like doing dressing and giving medicines. Nursing included mostly cleaning, laundry, and scrubbing.

The lack of hygienic and sanitation and increasing poverty in urban resulted in serious health problems in 15th to 17th century. Sisters cared for people in hospitals asylums and poor houses. They did home visiting also to care of the needy.

Mrs. Fliedner in 19th century wrote notes on nurses training. The first ever written by a woman and taught practical nursing. She also taught religion and ethics. The method employed for training nurses during this period become a model for modern secular

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nursing and attracted many visitors including Florence nightingale and Mrs. Elizabeth fry.

Modern nursing:

Florence Nightingale era:-

Florence Nightingale was borne on 12th may 1820 in Florence, Italy to an English wealthy family. She was interested in charitable work and became familiar with catholic sisters and American missionaries. In her quest to become a nurse she visited Kaisers worth hospital and was impressed by its systematic nursing programmed. She enrolled herself to the nursing training programmed in 1847. In 1853 she had an opportunity to study under ‗Sisters of charity‘ in London. During this period she brought about major reforms in hygiene, sanitation and nursing practice and reduced the mortality rate of the Barracks hospital in Scutari, Turkey from 42.7% to 2.2% in 6 months

Nightingale was the superintendent of nurses at king‘s college hospital until she left to take care the wounded soldiers during the Crimean war in 1854. Secretary of the war sir Sydney her best requested Florence nightingales help and she was accompanied by 38 nurses reached sciatic on 4th Nov. 1854 to Barnacle hospital. She demonstrated her skills as an administrator. She spent her own money to improve the conditions of diet kitchen and saw that diets are given according to the needs of the patients. She improved the conditions and sanitation facilities.

In 1960 she wrote nursing philosophy which reflected the changing needs of the society. She saw the role of nursing as having changing of somebody‘s health based on the knowledge of how to put the body in such a state to be free from the disease or to recover from disease.

Florence nightingale developed the first organized nursing school in 1860 at St. Thomas hospital London. She was honored as a national heroine by the queen. It was opened with 15 students. Duration of the programmed was one year.

The courses study included class room and bed side classes by the sister. Theoretical classes and examination by the doctors and each nurses was to keep note book on which she kept a record of her daily observations, treatment and care given to her patients. In 1865 Nightingale drew some detail suggestions or system of nursing in hospitals in India. This was the beginning of modern nursing in India. Nurses were recruited in India for first time in 1914.

As a result of her work the attitude towards nursing was changed. Between 1860 – 1893 the nightingale system of training spread all over the world by graduates from the school. Growth of contemporary nursing (19th century):

Shortly before world war 2nd, curriculum in school of nursing was revised with more emphasis on social sciences. Preventive and social aspects were integrated. During post world war 2nd development of nursing was on to the specialty areas like psychiatry, neurology. Major factors influenced health care development through nursing.

In 1869, American medical association developed committee on the training of nurses. As a result hospital based school of nursing of nursing under medical supervision emerged.

1n 1847, Linda Richards, Americas first trained nurse, graduated from women hospital, Boston. Lillian Wald and Mary Brewster established the first public health nursing service towards the end of 19th century. During World War 1 and 2nd the nurses had to

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take much independent judgment because physicians were serving the armed forces overseas. Then it was realized and accepted that nurses were also able to take decisions safely and were able to provide effective care to the injured.

The civil war (1861- 1865) stimulated the growth of nursing in the United States. After the civil war, nursing schools in the United States and Canada began to follow the nightingale plan. Nursing in hospitals expanded in the late nineteenth century, but nursing in the community did not increase significantly until 1893, when Lillian Wald and Mary Brewster opened the Henry street settlement. It was one of the first community health services to focus on the health needs of poor people living in the New York City tenements. Nurses working in this settlement had greater responsibility for their clients than nurses working in hospitals because they frequently encountered situations that required action independent of physician‘s orders.

In the eighteenth century, the growth of cities brought an increase in the number of hospitals and a greater role for nurses. Smallpox epidemics in the French colonies increased the need for nursing services.

Growth of nursing in 20th century:

Nursing education from 1900 to 1935 was predominantly based in hospital diploma programs. Of the more than 1800 diploma programs in existence in the mid 1930s less than 100 baccalaureate nursing programs were available for general nursing education. In 1923 the Rockefeller foundation funded a survey of nursing education, the Gold mark report. The report concluded that nursing education needed increased financial support and suggested that the money be given to university schools of nursing. As a result nursing programs such as those at Yale University and Vanderbilt University received funds for expansion.

As the nursing education developed, nursing practice also expanded. In 1901 the army nurse corps was established, followed in 1908 by the navy nurse corps. Nursing specialization was also developing. In the 1920s graduate nurse midwifery programs began, and beginning in the 1950s specialty organizations such as the association of operating room nurses (1949) were formed.

The classic Brown report of 1948 written by Dr. Esther Lucille Brown, a social scientist, significantly changed the course of nursing education. She examined nursing service and education from a societal perspective. Her report, funded by the Carnegie Foundation suggested all nursing education programs affiliate with universities and has their own budgets.

By 1952 Dr. Mildred Montage expanded current nursing education systems. These systems created the associate degree nursing program, offering a third educational track for the basic nursing student. By 1988 only 9% of graduating nurses had a diploma education, 33% had a baccalaureate degree, and the remaining 58% had associate degrees (NLN, 1990).

At 1953 work of the national league for nursing (NLN) with universities began to develop graduate nursing programs nationwide. Nursing at the doctoral level was initiated by New York University as early as 1934. As of 1988 there were 46 doctoral nursing programs (NLN, 1990).

The 30 years of educational and practice changes from the 1950s to the 1980s expanded specialization for nurses. Margareta Styles and Inez Hinsvark edited the American