The history of nursing, a segment of the white collar service sector, reflects the general trends in the transformation of work that gave rise to the new, dependent, salaried, white collar workforce, in conflict over the construct of professionalism. Although previously independent practitioners, by the end of World War II, a decisive majority of nurses were forced to find employment in the newly emerging bureaucratic hospitals as their opportunities for autonomous nurse-patient relationships diminished (Melosh 32).
In the nation's hospitals, nurses were subject to processes of bureaucratic control very much like those described by Edwards for both production and nonproduction workers (Edwards 17). Invisible mechanisms of control, including the human capital notion of professionalism and the use of written rules to govern nurses' tasks and supervision, were invoked to discipline this white collar workforce. Historically, nurses' responses to these constraints have been filled with conflict.
In the 18th century, nursing was merely another of women’s domestic chores. By the early 19th century, however, nursing had emerged as an occupation performed by respectable working-class women, primarily widows and spinsters. It was a specialty within domestic service, consisting primarily of cleaning a patient's body, linen, and dressings. This kind of labor was considered by most 19th-century men and women as an extension of woman's "natural" biological capacity for domesticity, docility, nurturance, and willingness to sacrifice (Berg 21).
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A fine line separated the 19th-century nurse from the domestic servant, as both were expected to perform household chores. By 1868, however, they were more clearly differentiated by salary; the nurse earned $1.00 to $2.00 a day whereas the servant earned only $2.22 per week (Reverby 9). Because of the close association with dirty domestic work, few middle-class women entered nursing. Until the Civil War, nursing remained an occupation performed by poor, older, single women with no formal education or training. These women were often drawn from rural areas into the cities in search of paid work, where their options were generally sewing, lodging borders, domestic service, or nursing. By 1870, there were over 10,000 women officially employed as nurses in the United States.
Until the 20th century, hospital nursing was less prevalent than household nursing since most births, deaths, and illnesses occurred in the home. The majority of Americans did not see the inside of a hospital until the turn of the century. Hospitals were barely hospitals as we now know them. They were charitable institutions built by philanthropists at the end of the 18th century for the poor, the socially marginal, or the unemployed. Indeed, many hospitals evolved out of public almshouses.
Patients in both public and voluntary hospitals were incarcerated for dependence as much as for disease in the 1870s (Vogel 105), and their hospital stay was often for weeks or months, not days. Impermeable walls and guarded gates surrounded the institutions, enabling hospitals to assert some control over the working class, immigrant, or destitute patient.
Although benevolent, hospitals treated their patients disdainfully, with authoritarianism and paternalism. Their purpose was to provide the patient with moral uplift while instilling social control. Hospital administrators believed their patients were from "the very lowest; from abodes of drunkenness and vice in almost every form, where the most depressing and corrupting influences were acting on both body and mind" (Vogel 24).
Children were decontaminated upon arrival and taught "discipline, purity and kindness." The trustees hoped this regimen would reform the children, who would then bring "newly refined manners, quickened intellect and softened hearts" back to their homes. Some hospitals attempted to reform adults as well because they believed society benefited not just by saving these workers but also by "rekindling in them their faith in social order" (Vogel 26).
Nurses in these hospitals were generally ambulatory patients themselves, caring for fellow "inmates." If not actual patients, hospital nurses originated from the same poor and working-class sectors of society as the patients. They often held several jobs simultaneously and were frequently reprimanded for "sewing-out" (manufacturing garments on the ward) while on duty (Reverby 24).
The status of the 19th-century hospital nurse was very low, comparable to the status of all female patients at this time. The female patient of 1870 was characterized in a letter to the Boston Evening Transcript as "a woman who has fallen into the sins of the wayside... too weak to resist the temptations which have beset their unguarded footsteps" (Vogel 26). Similarly, the hospital nurse was characterized by Florence Nightingale, the 19th-century British reformer, as "too old, too weak, too drunk, too dirty, too stolid or too bad to do anything else" (Reverby 26). Hence, stringent rules governing general behaviors regarding sex, language, and use of alcohol and tobacco were enforced for both patients and nurses in the hospital.
Although nurses lived in close proximity to the patients, they were forbidden to socialize with them. In order to prevent them from socializing or drinking with the patients, nurses were kept busy from 5:00 a.m. until 9:30 p.m. They were continually scrubbing patients, garments, and wards, since sanitation was the only method of disease prevention in the 19th-century hospital. When they had completed these tasks, they were given innumerable others to keep them in line.
In addition to such domestic tasks, nurses were often responsible for providing more serious health care in the doctor's frequent absence as well. They often managed labor and delivery cases independently. This forced nurses to exercise independent medical judgments, despite doctors' prevailing expectation that nurses would be completely subservient to them. With the taste of autonomy, nurses began to expect greater latitude in their work. They began to see themselves as adult wage workers, not children to be controlled by the hospital "family," as the hospital trustees portrayed the workplace.
The face of nursing changed during the Civil War. Middle- and upper-class women, motivated by patriotism, familial duty, or simply a search for meaningful work, began to work in hospitals, nursing wounded men, and raising funds for the war (Mottus 65).
The unsanitary and disorganized conditions in army hospitals led to the emergence of relief associations. In 1861 the Women's Central Association of Relief was formed with the explicit purpose of "furnishing comforts and medical stores, and especially nurses in aid of the medical staff of the army... and to take measures for securing a system of well trained nurses against any possible demand of war" (Mottus 24). Drawing on Nightingale's British model of army nursing, the Registration Committee on Nurses sought prospective applicants with specific qualifications: they were to wear dresses without hoops, provide references confirming their high moral character, and be no older than 45 years of age. Nurses trained according to Nightingale's nursing model, learning the laws of both morality and hygiene.
The post-Civil War years, characterized by remarkable economic growth, the rise of industrial corporations, the decline of small entrepreneurs, and the emergence of urban America, engendered the expansion of relief organizations and the development of new charity organizations. Both were controlled in large part by middle- and upper-class female reformers.
These women, many of whom had participated in organized nursing during the Civil War, focused on reforming the moral character of the poor, soiled by the ravages of urban society (Lubove 4-5). The expansion of the charity organization movement represented another response by a troubled middle class to the social dislocation of the post-Civil War industrial city: "Charity organization was a crusade to save the city from itself and from the evils of pauperism and class antagonism. It was an instrument of social control for the conservative middle class" (Lubove 5).
In the post-Civil War hospital, middle-class women joined forces with hospital trustees and developed training schools for nurses. The reformers' purpose was to "save" the country girl from the city, foster a profession of nursing, and reform the hospital. They attempted to carry out this goal by developing a cadre of trained, professional, middle-class nurses. The hospital trustees, however, sought nurses as a cheap labor force for the hospital.
During the depression years of the 1890s, the hospital moved away from being a charity organization (Rosner 119). Philanthropists, affected by financial crises themselves, were no longer able to be the sole supporters of the institutions. Hospital trustees turned to the middle-class patient as a new source of income for hospitals. This change motivated trustees to alter the hospital's architecture as well as its workforce. Its image became more hotel-like, with private rooms, private doctors, and private nurses.
The reformers convinced the trustees that young, educated nurses of middle-class origins would be more appropriate caretakers for wealthier patients than untrained, working-class nurses. Hence, while the middle-class reformers were attempting to create a profession for respectable middle-class women, embodying Victorian America's idealized vision of upper-class womanhood (empathy, gentility, and dedication to service), the trustees were still seeking an inexpensive yet disciplined workforce. The middle-class student nurse was their answer.
One of the first training schools for nurses emerged in 1889 at the Johns Hopkins Hospital as a joint effort between the women reformers and the hospital trustees. They sought applications from Episcopalian and Presbyterian daughters of the clergy and the professions (James 214). The reformers hoped such a school would become the new social incubator for daughters of the new middle class. They sought only educated and refined students; women who had previously worked in the mills or domestic service were discouraged from applying. The reformers argued that only women with proper, virtuous backgrounds could enhance the moral atmosphere of the hospital.
Student nurse training meant working 13-hour days at domestic duties under strict military discipline. Understaffing and medical emergency continually forced students into positions for which they were unprepared. These poor work conditions of overwork, lack of adequate training, bad food, and arbitrary discipline took their toll on the students, resulting in the 1910s in strikes against nursing supervisors (Reverby 37).
During the 1930s and into the 1940s the private duty market collapsed altogether (Melosh 197). The new array of hospital techniques for both patients and nurses fostered a new role for some nurses, however: that of hospital foreman, supervising a new hierarchy of subsidiary nurses. The nursing professionalizers urged hospital administrators to hire educated graduate nurses of middle-class origins for these positions. Administrators were not hard to persuade on this point since they were able to hire nurses with more education and experience for the same wage as the student nurse, given depression-era unemployment.
At first, grateful for work, graduate nurses accepted this condition. In time, however, graduate nurses responded to this situation with unrest, high rates of absenteeism, and turnover. Conflicts between adherents of the more elitist, human capital interpretation of professionalism and proponents of the need to work continue to resonate from staff and head nurses today. Many staff nurses claim that besides taking care of patients, they’re working to put shoes on their children’s feet and nursing administrators just don't see that they work to support their life outside the hospital too. Such a comment was just as appropriate in the 1880s as it was in 1985. The same debates still rage on.
Besides, there are two current health care issues facing the profession of nursing today: a misdistribution of nurses across the United States and burnout, both noted as causes for a nursing shortage. There is a misdistribution of nurses across the United States and there are at least two apparent reasons for this: geographic immobility and a lack of incentives for rural and inner-city hospitals. Nursing is a very demanding and stressful profession.
Burnout is described by Annette T. Vallano in Your Career in Nursing, as a form of mental, physical, emotional, spiritual, and interpersonal exhaustion that is not easily restored by sleep or rest. Nurses experience burnout when they are overwhelmed and unable to cope with the day-to-day stress of their work over long periods of time. Burnout may also be a reason that many nurses have decided to work only part-time, thus burnout may be a contributing factor to the nursing-shortage problem.
All in all, nursing has evolved from the days of Florence Nightingale to a highly respected and educated profession. But there are challenges for the future. In short, “the nursing profession needs to begin to recognize new trends and patterns” (Lowenstein1), while also recognizing “it is crucial that nurses learn to generate new ideas for care, utilizing the new medical and communication technologies that are blossoming daily, but also keeping our high touch together with the high tech” (Lowenstein 1).
Edwards, Richard. Contested Terrain: The Transformation of the Workplace in the Twentieth Century. New York: Basic Books. 1979.
Berg, Barbara. The Remembered Gate: Origins of American Feminism: The Woman and the City, 1800-1860. New York: Oxford University Press. 1978.
James, Janet. "Isabel Hampton and the Professionalization of Nursing in the 1890s". In Charles Rosenberg and Morris Vogel (eds.), The Therapeutic Revolution. Philadelphia: University of Pennsylvania Press. 1979.
Lowenstein, Arlene. “Vision for the future of nursing.” ICUS NURS WEB J, 16, Oct/ Dec 2003 http://www.nursing.gr/editorialLowenstein.pdf.
Lubove, Roy. The Professional Altruist: The Emergence of Social Work as a Career, 1880-1930. Cambridge: Harvard University Press. 1965.
Melosh Barbara. The Physician's Hand: Work Culture and Conflict in American Nursing. Philadelphia: Temple University Press. 1982.
Mottus, Jane E. New York Nightingales: The Emergence of the Nursing Profession at Bellevue and New York Hospital, 1850-1920. Ann Arbor: University Microfilms International. 1980.
Reverby, Susan. Ordered to Care: The Dilemma of American Nursing, 1850-1945. New York: Cambridge University Press. 1987.
Rosner, David. A Once Charitable Enterprise: Hospitals and Health Care in Brooklyn and New York, 1885-1915. New York: Cambridge University Press. 1986.
Vallano, Annette. Your Career in Nursing. Kaplan; 3rd edition. January 3, 2006.
Vogel, Morris. The Invention of the Modern Hospital, Boston, 1870-1930. Chicago: University of Chicago Press. 1980.
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