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Chapter 2

History and Social Contexts of Nursing

PNURS 210

Introduction to Professional Nursing

Sandy Parker, MSN, RN

Mid-19th Century Nursing in England

Florence Nightingale

Training: Kaiserswerth, Germany and Sisters of Charity, Paris

Crimean War (1854–1956) – hospital set-up in Scutari, Turkey

Data collection on morbidity and mortality helped reform the British medical system.

1859: Notes on Nursing: What it is and what it is not – a body of nursing knowledge and professional nursing

1860: Established first training school for nurses at St. Thomas’ Hospital in London

Florence Nightingale

Trained in basic nursing Kaiserswerth, Germany and Sisters of Charity in Paris

Care of the sick was often in the purview of women and men in religious orders.

Crimean War (1854–1856)

Nightingale took 38 nurses to the British hospital in Scutari, Turkey

organized and cleaned the hospital and provided care to the wounded soldiers

Nightingale collected very detailed data on morbidity and mortality of the soldiers in Scutari - reform of the entire British Army medical system

Nightingale and the first training school for nurses at St. Thomas’ Hospital in London in 1860

1859 Notes on Nursing: What It Is and What It Is Not – a body of nursing knowledge and professional nursing

Mid-19th Century Nursing in England

Gill and Gill (2005):

“Nightingale’s influence today extends beyond her undeniable impact on the field of modern nursing to the areas of infection control, hospital epidemiology, and hospice care” (p. 1799).

Mid-19th Century Nursing in England

Mary Seacole (1805–1881)

Jamaican nurse and businesswoman. Greatest black Briton.

Did not work with Nightingale during the Crimean War. She was rejected by Nightingale.

Expert on cholera – managed the care of the soldiers of Crimea

“Was it possible that American prejudices against colour had some root here? Did these ladies shrink from accepting my aid because my blood flowed beneath a somewhat duskier skin than theirs?” (Spartacus Educational, 2014)

Mary Seacole (1805–1881) and Crimean War

Jamaican nurse and businesswoman

“the greatest Black Briton” in history in a 2003 poll and campaign to raise the profile of contributions of Blacks to Britain over the past 1000 years (100 Great Black Britons, 2015). Seacole did not refer to herself as a nurse despite her desire to be part of Nightingale’s team of nurses going to the Crimea. Her request to be part of the team was refused.

An independent woman with some wealth, Seacole funded her own travel to the Crimea where her offer to be of service at the British hospital run by Nightingale was again refused.

Seacole later reflected in her 1857 autobiography Wonderful Adventures of Mrs. Seacole: “Once again I tried, and had an interview this time with one of Miss Nightingale’s companions. She gave me the same reply, and I read in her face the fact that, had there been a vacancy, I should not have been chosen to fill it . ... Was it possible that American prejudices against colour had some root here? Did these ladies shrink from accepting my aid because my blood flowed beneath a somewhat duskier skin than theirs?” (Spartacus Educational, 2014).

Still undeterred, Seacole then established a hotel for injured soldiers and visited the battlefield to tend to the injured and sick. Seacole had a great deal of experience in the management of cholera because of an outbreak in Panama while she was visiting her brother; cholera and other infectious diseases were the cause of a huge percentage of deaths of soldiers in the Crimea. In her autobiography, Seacole described performing an autopsy on a small child who had died of cholera in Panama, the results of which she did not make public but which shaped her understanding of the effects of cholera and how it should be managed. Criticism of Seacole surrounds her entrepreneurship – she sold food and drinks during the war to officers and spectators (Spartacus Educational, 2014).

Called “Mother Seacole” by British soldiers, news accounts of the day described her as a heroine, compassionate, fearless, and determined. Many referred to her as a physician or “doctress”; however, an article in 2012 published in the London newspaper The Daily Mail referred to Seacole as “our greatest Black Briton, a woman who did more to advance the cause of nursing and race relations than almost any other individual  she is said to have saved the lives of countless wounded soldiers and nursed them to health in a clinic paid for out of her own pocket” (Spartacus Educational, 2014). After Seacole filed for bankruptcy soon after her return to England, 80,000 persons attended a 4-day fund-raising event organized in her honor.

She was a beloved figure in England, described in 2013 by a writer Hugh Muir for The Guardian as not a threat to the legacy of Nightingale but as a woman who “reigned on the battlefield.” The context for Muir’s remarks is an ongoing controversy among politicians and historians about whether Seacole’s story will continue to be taught to schoolchildren in a national curriculum, and whether to erect a monument to Seacole that is larger than the one honoring Nightingale (Spartacus Educational, 2014).

With regard to capitalization, please leave all references to race (Black or White) capitalized.

1861–1873: The American Civil War An Impetus for Training for Nursing

No available professional nurses at the start of the Civil War.

Catholic orders served as nurses.

Call to duty: Emergence of nurses and nurse leaders

Dorothea L. Dix – superintendent of women nurses by union army. Trained nurses who were employable post-war.

Sojourner Truth (abolitionist) and Harriet Tubman (former slave, led slaves to freedom) as nurses

Susie King Taylor – taught soldiers to “read and write”

1861–1873: The American Civil War An Impetus for Training for Nursing

Call to duty: Emergence of nurses and nurse leaders

Mary Ann (“Mother”) Bickerdyke – lay person who made cleanliness a priority (brought “order out of chaos”)

Clara Barton (“Angel of the Battlefield”) – set-up field hospital for the wounded and dying in Culpeper, Virginia. Founded American Red Cross

1861–1873: The American Civil War An Impetus for Training for Nursing

Call to duty: Women of the South

Superintendent Sallie Thompkins – “captain of Calvary” by Confederate President Jefferson Davis.

Phoebe Pember – matron of hospital (Chimborazo Hospital in Richmond, Virginia)

Civil War and Nursing

It helped advance professional nursing practice. These leaders, though largely untrained, achieved dramatic improvements in care.

The success in the reform of military hospitals served as a model for reform of civilian hospitals nationwide.

After the Civil War: Moving toward Education and Licensure under the Challenges of Segregation

1861: Sanitary Commission – relief agency to support wounded and sick soldiers

Lobby for creation of nursing schools (Donahue, 1996)

1869: American Medical Association meeting. Chair – Samuel Gross

Recommend training schools for nurses in large hospitals

Inadequate conditions in many hospitals sparked the need for social reform.

First Training Schools for Nurses and Feminizing of Nursing

1873 – Nightingale school-modeled training schools in America

Bellevue Training School for Nurses in New York City

Connecticut Training School for Nurses in New Haven

Boston Training School for Nurses at Massachusetts General Hospital in Boston

Mary Eliza Mahoney-first educated, professionally trained African American nurse

Linda Richards – first trained nurse in the US

Victorian belief – feminine qualities in a nurse + men prevented from entering the profession

1900 – nursing schools provided steady, subservient, female, student nurse, hospital workforce

First Training Schools for Nurses and Feminizing of Nursing

Segregation in Nursing

New England Hospital for Women and Children, Boston – admitted one African-American and Jewish student who met qualifications

1886 – Atlanta Baptist Female Seminary (later: Spelman College) in Atlanta, GA. 2-year-long diploma program.

Closed: 1928. Graduated 117 nurses.

1886 – School for Male Nurses, NY Training School

1888 – Mills College of Nursing at Bellevue Hospital

1898 – Alexian Brothers Hospital, Chicago

1928 – Alexian Brothers Hospital, St. Louis

Mary Eliza Mahoney is the first African American professionally educated nurse, received her training New England Hospital for Women and Children

Male students were not allowed in the early nursing schools that enrolled women.

The Alexian Brothers ministry dates back to the Middle Ages in Europe, where they tended to the sick and hungry and, in the mid-1300s, cared for victims of the Black Plague that devastated the continent. The Alexian Brothers Health System still exists today.

Professionalization through Organization

1893: Chicago World’s Fair – meeting of the minds

Isabel Hampton Robb – protested the lack of uniformity across nursing schools (inadequate curriculum development and nursing education)

1896: Founded Nurses’ Associated Alumnae of the United States and Canada

1911: It became American Nurses Association

The meeting included: Isabel Hampton Robb, Lavinia Lloyd Dock, and Bedford Fenwick of Great Britain.

A paper by Florence Nightingale on the need for scientific training of nurses was presented at this same meeting.

Professionalization through Organization

1893: Chicago World’s Fair – meeting of the minds

National League for Nursing, the American Society of Superintendents of Training Schools for Nurses – was formed to address issues in nursing education

1912: National League of Nursing Education (NLNE)

1952: National League for Nursing (NLN).

The meeting included: Isabel Hampton Robb, Lavinia Lloyd Dock, and Bedford Fenwick of Great Britain.

A paper by Florence Nightingale on the need for scientific training of nurses was presented at this same meeting.

Nursing’s Focus on Social Justice: The Henry Street Settlement

Early in 20th Century

Influx of immigrants and factory work in northeastern US

Infections and overcrowding in inner city tenements

1893: Establishment of Henry Street Settlement

Lillian Wald and Lavinia Dock

They sought finances and formalized public health.

They treated minor illnesses, prevented disease transmission, and provided health education.

Margaret Sanger and Lower East Side (Kennedy, 1970)

Immigrant women

Safe contraception and family planning

https://www.henrystreet.org/

Margaret Sanger’s work was sometimes dangerous and always controversial, yet she persisted in her work to preserve reproductive and contraceptive rights for women.

The Henry Street Settlement still functions today to fight urban poverty in New York’s Lower East Side, serving all ages with a variety of health services, social services, and the arts. Short video: www.henrystreet.org.

A Common Cause, but Still Segregated

Tuberculosis and African Americans

Racial barriers and cultural resistance to seeking medical care

Provide a Black district nurse to work with African Americans

Jessie Sleet Scales and “A Successful Experiment”

With Elizabeth Tyler – established Stillman House (a branch of Henry Street Settlement)

They focused on disease prevention and management of illness.

The Stillman House signifies activism, expansion, and growth.

Tuberculosis and tenements of newly developing cities

Dr. Edward T. Devine, president of the Charity Organization Society, noted the high incidence of tuberculosis among New York City’s African American population.

Racial barriers and cultural resistance to seeking medical care, Dr. Devine determined that a Black district nurse should be hired to work in the African American community to persuade people to accept treatment.

Jessie Sleet Scales, an African American nurse trained at Providence Hospital in Chicago, was hired as a district nurse on a trial basis. Her report to the Charity Organization

Society was published in the American Journal of Nursing in 1901, titled “A Successful Experiment”:

I beg to render to you a report of the work done by me as a district nurse among the colored people of New York City during the months of October and November. I have visited forty-one families and made 156 calls in connection with these families, caring for nine cases of consumption, four cases of peritonitis, two cases of chickenpox, two cases of cancer, one case of diphtheria, two cases of heart disease, two cases of tumor, one case of gastric catarrh, two cases of pneumonia, four cases of rheumatism, and two cases of scalp wound. I have given baths, applied poultices, dressed wounds, washed and dressed newborn babies, cared for mothers. (Sleet, 1901, p. 729)

Jessie Sleet Scales later recommended to Lillian Wald that Elizabeth Tyler, a graduate of Freedmen’s Hospital Training School for Nurses in Washington, DC, work with African American patients at the Henry Street Settlement.

Scales and Tyler established the Stillman House, a branch of the Henry Street Settlement serving Black persons in a small store on West 61st Street.

Community health nursing – The Stillman House signified activism, expansion, and growth

Scales and Tyler succeeded in providing excellent nursing care to underserved families with increasing but manageable health problems.

Common focus: prevention of disease and management of illness

Spanish-American War Creates the Need for Nurses

1898: US Congress declared war on Spain.

Anita M. McGee MD – head of Hospital Corps

Recruitment of graduate nurses

Typhoid epidemic created a greater need for nurses

Namahyoke Curtis – contract nurse, first trained African American

Development of Army Nurse Corps (1901) and Navy Nurse Corps (1908)

In 1898, the U.S. Congress declared war on Spain, and once again, nursing had a major role in the care of the sick and injured in war.

Anita M. McGee, MD, was appointed head of the Hospital Corps, a group formed to recruit nurses. Encouraged by Isabel Hampton Robb and the fledgling Nurses’ Associated Alumnae of the United States and Canada, McGee initially wanted only graduates of nurse training schools in the Hospital Corps (Wall, 1995); however, it soon became clear that this requirement could not be met. A widespread epidemic of typhoid fever created a greater need than anticipated, and as a result others, including the Sisters of the Holy Cross and untrained African American nurses who had had typhoid fever in the past, were accepted for service (Wall, 1995).

Namahyoke Curtis was employed as a contract nurse by the War Department during the Spanish-American War, making her the first trained African American nurse in this capacity. Although McGee and Robb had to enlist untrained persons to care for the sick and wounded during the Spanish-American War, their efforts set the stage for the development of a permanent Army Nurse Corps (1901) and Navy Nurse Corps (1908)

Professionalization and Standardization of Nursing through Licensure

The institution of state licensure for nurses was a huge milestone for nursing in the early 20th century, although early efforts at licensure were not well received.

After an educational campaign, the ICN passed a resolution asking each country and state to provide for licensure of the nurses working there. As a result, state legislatures in New Jersey, New York, North Carolina, and Virginia passed what were known as permissive licensure laws for nursing in 1903. Nurses did not have to be registered to practice but could not use the title of registered nurse (RN) unless they were registered.

By 1923 all states required examinations for permissive licensure, but the examinations were not standardized. It was not until the 1930s that New York became the first state to have mandatory licensure; however, this was not fully mandated until 1947. In 1950 the NLN assumed responsibility for administering the first nationwide State Board Test Pool Examination.

The first edition of the American Journal of Nursing, published in October 1900, was a key event of this decade. Nurse leaders Isabel Hampton Robb, Mary Adelaide Nutting, Lavinia L. Dock, Sophia Palmer, and Mary E. Davis were heavily involved in the development of the journal. Sophia Palmer, director of nursing at Rochester City Hospital, New York, was appointed as the first editor, with the goal of presenting “month by month the most useful facts, the most progressive thought and the latest news that the profession has to offer in the most attractive form that can be secured” (Palmer, 1900, p. 64).

Early 20th century – early efforts at licensure

ICN resolution: Each country and state to provide for licensure of the nurses

1903: Permissive licensure laws: Nurses did not have to be registered to practice but could not use the title of registered nurse (RN) unless registered.

1923: All states required permissive licensure

1947: New York fully mandated licensure

1950: NLN and first nationwide State Board Test Pool Examination

1917–1930: The Challenges of the Flu Epidemic, World War I, and the Early Depression Era

1917: US entered World War I and influenza pandemic

Mary Adelaide Nutting and National Committee on Nursing

Charged with adequate supply of nurses

Army School of Nursing with Annie Goodrich as dean

Vassar Training Camp for Nurses

Red Cross nursing – widespread public education in home care and hygiene

1920: Congress passed a bill that provided nurses with military rank.

1917–1930: The Challenges of the Flu Epidemic, World War I, and the Early Depression Era

1923: Goldmark Report – study of nursing education

Advocated for establishment of schools of nursing associated with colleges and universities

Encouraged establishment of rural programs of midwifery

1925: Mary Breckinridge and Frontier Nursing Service

Implication: Through this rural midwifery service, Breckinridge demonstrated that nurses could play a significant role in providing primary rural health care.

Goldmark report – study of nursing education that advocated for establishment of schools of nursing associated with colleges and universities (rather than hospital-based diploma program) and encouraged establishment of rural programs of midwifery.

1925: Frontier Nursing Service (FNS)

Mary Breckinridge – nurse and midwife

Originally established as the Kentucky Committee for Mothers and Babies,

First organized midwifery program in the United States.

Nurses of the FNS worked in isolated rural areas in the Appalachian Mountains, traveling by horseback to serve the health needs of the poverty-stricken mountain people.

FNS nurses delivered babies, provided prenatal and postnatal care, educated mothers and their families about nutrition and hygiene, and cared for the sick.

Through this rural midwifery service, Breckinridge demonstrated that nurses could play a significant role in providing primary rural health care.

1931–1945: Challenges of the Great Depression and World War II

With hospitals largely staffed by nursing students, most nurses who had completed their training worked as private duty nurses in patients’ homes.

The Great Depression – many families could no longer afford private duty nurses, forcing many nurses into unemployment.

1933: President Franklin D. Roosevelt established the Civil Works Administration (CWA) in which nurses participated by providing rural and school health services. They also took part in specific projects such as conducting health surveys on communicable disease and nutrition of children. Hospitals, as a result of the severe economic conditions of the Depression, were forced to close their schools of nursing. Consequently, hospitals no longer had a reliable, inexpensive student workforce at the time when there was a significant increase in the number of patients needing charity care. The solution soon became apparent: unemployed graduate nurses, willing to work for minimum pay, were recruited to work in the hospitals rather than doing private duty for wealthy families. This had a lasting effect on the staffing of hospitals.

Social Security Act (SSA) of 1935, a significant part of President Roosevelt’s plans to bring the nation out of the Depression, enhanced the practice of public health nursing. Purpose: to strengthen public health services and to provide medical care for children with disabilities and blind persons.

With funds from the SSA, public health nursing became the major avenue for the provision of care to dependent mothers and children, the blind, and children with disabilities (Cherry and Jacob, 2005).

The Great Depression: Many families could no longer afford private duty nurses, forcing many nurses into unemployment.

1933: President Franklin D. Roosevelt and Civil Works Administration

Social Security Act of 1935 enhanced the practice of public health nursing.

World War II: Challenges and Opportunities for Nursing

The need for more nurses

Congress enacted substantial support for nursing education

Military and collegiate programs of nursing formed the Cadet Nurse Corps.

Schooling in exchange for commitment to serve (Robinson and Perry, 2001)

1943–1948: 124,000 nurses volunteered, graduated, and certified for military services in the Army and Navy Nurse Corps

During World War II and need for nurses

Congress enacted legislation to provide substantial financial support for nursing education.

Military and collegiate programs of nursing formed the Cadet Nurse Corps, an alliance to train student nurses. Students received tuition, books, a stipend, and a uniform in return for a commitment to serve as nurses for the duration of the war in either civilian or military hospitals, the Indian Health Service, or public health facilities (Robinson and Perry, 2001).

Approximately 124,000 nurses volunteered, graduated, and were certified for military services in the Army and Navy Nurse Corps between 1943 and 1948.

Despite ongoing racial segregation, African American collegiate programs, as well as the NACGN, were active participants in the Cadet Nurse Corps.

Historical Note 2-4 describes the courage of nurses in the Philippines at Corregidor and the Bataan during the World War II, who were held in captivity for 3 years in an internment camp.

1945–1960: The Rise of Hospitals—Bureaucracy, Science, and Shortages

1946: Hill-Burton Act

Growth of new facilities and increased need for nurses

Collective bargaining

Team nursing and associate degree in nursing

1947: Military nurses were awarded full commissioned officer status in both Army and Navy Nurse Corps.

End of segregation

Julie O. Flikke – first nurse to be promoted to the rank of colonel in US Army

1954: Men allowed in military nursing corps

1947: Military nurses were awarded full commissioned officer status in both the Army and the Navy Nurse Corps and segregation of African American nurses was ended. Julie O. Flikke was the first nurse to be promoted to the rank of colonel in the U.S. Army.

1954: Men were allowed to enter the military nursing corps.

1946: Hill-Burton Act was enacted, providing funds to construct hospitals - surge in the growth of new facilities.

acute shortage of nurses

increasingly difficult working conditions – long hours, inadequate salaries, and increasing patient loads

strikes and collective bargaining

“team nursing”

institution of the associate degree in nursing

Journal of Nursing Research was first published.

1961–1982: The Great Society, Vietnam, and the Change in Women’s Role

1960: Era of specialty care and clinical specialization

1965: Social Security Act amended

Medicare and Medicaid

Reliance on Medicare an Medicaid reimbursements

Hospital as preferred care (and work) setting

Vietnam War

Mobile hospitals and nurses

Beyond the roles and responsibilities

PTSD among nurses and soldiers

1965 – two amendments to the Social Security Act, designed to ensure access to health care for elderly, poor, and disabled Americans, resulted in the establishment of Medicare and Medicaid.

Hospitals and reimbursements from Medicare and Medicaid

Hospitals as preferred place of employment for nurses

1960s: specialty care and clinical specialization for nurses

Clinical specialist role in psychiatric nursing—combined with the proliferation of intensive care units and technological advances of the period—fostered the growth of clinical specialization in many areas, including cardiac-thoracic surgery and coronary care.

The increase in medical specialization, along with the concurrent shortage of primary care physicians and the public demand for improved access to health care that grew out of President Lyndon B. Johnson’s “Great Society” reforms, fostered the emergence of the nurse practitioner (NP) in primary care.

1971: Idaho became the first state to recognize diagnosis and treatment as part of the legal scope of practice for NPs.

Vietnam War – provided nurses with opportunities to stretch the boundaries of the discipline.

The Vietnam War occurred in jungles not easily accessed by rescue workers or medics and without clearly drawn lines of combat.

Mobile hospital in jungles

Nurses often worked without the direct supervision of physicians

They performed advanced emergency procedures such as tracheotomies and chest tube insertions, never before executed by nurses.

They also had to deal with the lack of support at home – Vietnam War was controversial and was widely protested.

The trauma of the battlefield was intensified by this lack of support at home, and many nurses suffered posttraumatic stress disorder, as did the returning soldiers.

In 1993 the Vietnam Women’s Memorial statue was dedicated, which featured two nurses—one White, one Black—tending to the prostrate figure of an injured soldier. Most of the American women who served in Vietnam were nurses. This memorial captured the difficult and crucial role of nurses in the Vietnam War, and stands in sharp contrast to the days of segregation from earlier decades. The Vietnam Women’s Memorial statue is featured on the title page of this chapter.

1983–2000: Challenges for Nursing—HIV/AIDS and Life Support Technologies

Early 1980s: HIV

Universal precautions

Changes in equipment – needles, IV catheters, gloves

1980 –1990s: Medical Technology and life support

Karen Ann Quinlan

Nancy Cruzan

Early 1980s: Recognition of the rapid spread of a retrovirus (later: human immunodeficiency virus (HIV)).

It was isolated from a person with acquired immunodeficiency syndrome (AIDS).

Believed to be confined to the gay community, in 1983 the first incidence of the spread of HIV was noted in hemophiliacs as a result of HIV-contaminated blood products.

Resulted in massive changes to the daily routines in health care, including the implementation of universal precautions.

Development of antiretroviral treatments

Materials such as needles, intravenous catheters, and gloves to global AIDS initiatives in resource-poor nations, particularly in Africa.

1980s and 1990s: enormous increase in the use of medical technologies, including the wide use of life support.

Ethical questions were raised during these years regarding the use of life support technologies and when they are appropriate.

Karen Ann Quinlan to discontinue ventilatory support after she lapsed into a drug- and alcohol-induced coma in 1975.

“persistent vegetative state” became well known, if not entirely understood, by the public.

Ms. Quinlan lived for a decade after the discontinuation of the ventilator, never regaining consciousness.

Nancy Cruzan, raised questions of “right to die” and what the patient would have wanted.

persistent vegetative state and her parents asked for her feeding tube to be removed, eventually taking their fight to the U.S. Supreme Court, which upheld a ruling by the Missouri court that prevented them from discontinuing her nutritional support. They eventually won a court order under the Due Process Clause that supports a person’s right to refuse medical treatment.

The Cruzans provided evidence that their daughter would have wanted her life support terminated, and they were allowed to have nutritional support discontinued. These prominent cases moved forward support for advance directives that would provide evidence of a patient’s wishes while still competent.

Karen Ann Quinlan and Nancy Cruzan

Before Terry Schiavo, there was Karen Ann Quinlan. On April 14, 1975, after an evening out with friends during which she consumed alcohol and sedatives, the 21-year-old New Jersey resident stopped breathing and lapsed into a coma. After five months, doctors diagnosed Quinlan as being in a persistent vegetative state; her parents, who believed there was no chance of her returning to consciousness and who wanted to end her suffering, requested that Quinlan be disconnected from the machines that were sustaining her. When her doctors refused, they took the case to court — in what became one of the the first "right to die" case in U.S. legal history. Based on the right to privacy, the court ruled that "no compelling interest of the state could compel Karen to endure the unendurable" and allowed her to be taken off life support. Her story made headlines and provided the groundwork for numerous similar cases. But Quinlan's story didn't end there: weaned from the respirator, she survived for nearly 10 more years, dying of pulmonary failure on June 11, 1985 in a New Jersey nursing home.

Nancy Cruzan was a 25 year old woman in 1983 when she was in a terrible car accident. She suffered traumatic injuries and had no vital signs such as breathing or heartbeat when she was found. The emergency responders did CPR to resuscitate her.

At the hospital she was put on ordinary care life support, which involves a feeding tube and hydration. Within about a month, her doctors determined that she was in a persistent vegetative state (PVS), and would not recover. This meant she had no brain function and could not respond to her environment. This is the point when several issues were raised.

2001–2015: The Post–9/11 Era, Natural Disasters, and Health Care Reform

2001: World Trade Center – Disaster management with focus on saving as many lives

2005: Hurricane Katrina – Provision of care under horrendous conditions

2006: ANA statement of nursing actions in “unfamiliar and unusual conditions”

2010: Affordable Care Act and incremental implementation

Information and medical technologies

2001: Aftermath of the World Trade Center attacks in New York City on September 11, 2001

Disaster management with a focus on saving as many lives as possible during a wide-scale disaster.

2005, Hurricane Katrina created a disaster along the Gulf Coast of Louisiana, Mississippi, and beyond.

Physicians, and other providers sought to protect and comfort patients under horrendous conditions.

2006: Arrest of two nurses for administering lethal doses of morphine and midazolam to four terminally ill patients in the aftermath of Hurricane Katrina

American Nurses Association (ANA) published comments on nursing care during disasters, citing the “unfamiliar and unusual conditions with the health care environment that may necessitate adaptations to recognized standards of nursing practice”;

the comments, however, did not address the specific details of these nurses’ situations. The ANA comments can be found at www.nursingworld.org/DocumentVault/Ethics/ANAonKatrina.html.

2010: Affordable Care Act (ACA), signed into law by President Barack Obama in March 2010

ANA supported the passage of this Act and in 2011 affirmed its continuing support for the Act in the face of efforts by subsequent sessions of Congress to repeal it. Provisions of the ACA were implemented over time.

Early provisions banned lifetime limits on insurance coverage by insurers so that patients with extreme medical costs can be assured of continuing benefits over the course of their illness and lifetime.

Young adults up to age 26 are now allowed coverage on their parents’ insurance plan unless they are offered insurance coverage at work.

The ACA also prevents insurance companies from denying coverage to children and teens younger than age 19 because of a preexisting condition. An estimated 162,000 children were estimated to benefit from these two provisions. Later provisions included coverage of recommended preventive services with no out-of-pocket expenses for insurance holders, the right to appeal coverage decisions, and having a choice of primary care providers.

By 2015, more than 16 million Americans had a health care plan under the ACA, meaning that only 10.1% were without health coverage, a decrease of more than 4% since the first ACA open enrollment in 2013. The Congressional Budget Office, a nonpartisan department of the federal government, estimated a cost savings of over $1.7 trillion over two decades. Interestingly, the ACA has improved patient safety and prevented an estimated 50,000 deaths between 2010 and 2013 from health care–related harm. An important provision of the ACA was that persons with a preexisting health condition could not be denied health insurance coverage. This provision affected 129 million Americans. Details of the ACA are available at www.whitehouse.gov/healthreform/healthcare-overview.

Informational and medical technologies

Digitalized health records allow for access across disciplines and across distance, with the goal to improve continuity of health care no matter where a person may require medical treatment. In many institutions, nurses enter patient data into computers at the bedside. Life-sustaining medical technologies have created new ethical challenges for nurses, who continue to be the first line of defense on behalf of their vulnerable patients. This role has never changed for nurses, even though technologies have altered the terrain of health care over time.

Many of the issues that confronted nurses of the past still confront nurses today.

War, infectious disease, poverty, and immigration still pose challenges to public health. With an increasing interest in global health, nurses are finding that, although many infectious diseases have been managed, HIV/AIDS and malaria still threaten the health of people in Africa and other underdeveloped parts of the world. Nurses are increasingly aware of the need for cultural competence in providing care to others with whom nurses share little in common demographically.

Monsivais (2011) noted that, although cultural markers such as age, gender, education, and socioeconomic class all create a certain cultural experience, the intersection of an illness along any or all of these markers may create an entirely different set of circumstances that challenge nurses to identify and address. More simply, the shared experience of a particular illness may create a subgroup with more cultural significance than an individual’s age, gender, or ethnic identity. For example, there is a sizable online community of parents who vary greatly across demographic indicators but who are connected through their children who have heart disease. These parents often refer to their children as “cardiac kids,” a signal of both their children’s serious health struggles and the lifestyle changes that are created around these conditions. Other illnesses such as cancer or genetic conditions have resulted in similar patient and family communities that reach beyond cultural markers.

Significant language barriers and Latinos

Wars in Iraq and Afghanistan – significant injuries that will require lifelong management

Profound lower extremity injuries among Middle East veterans and improvised explosive devices (IEDs), also known as roadside bombs

Social Context: Image of Nursing

Media depiction of nurses

Nursing caps and other forms of identification

First names versus last names. Gordon (2005), in an informal survey of approximately 30 lay people, found that the respondents did not think it would be odd for nurses to refer to themselves more formally.

Nurse Ratched in “One Flew Over the Cuckoo’s Nest” (1975)

2014 Gallup: Nurses were rated the highest among a number of professions and occupations on honesty and ethics.

National Population Trends: Aging of America

People are living longer.

The number of elderly people is increasing as the number of adults in early midlife is decreasing.

Profound effect on health care system and nursing profession

Current nursing strategies:

Care of elderly in nursing programs

Gerontology courses

Gerontological clinical nurse specialists and NPs

National Population Trends: Diversity

Africans and deep distrust of health care system

US Public Health Service Syphilis Study at Tuskegee

African Americans and Hispanics differed from Whites in that they expected discrimination in the health care system; in particular, African Americans expected to be experimented on, which fostered distrust (Jacobs, et al., 2011).

In 1932, the Public Health Service, working with the Tuskegee Institute, began a study to record the natural history of syphilis in hopes of justifying treatment programs for blacks. It was called the “Tuskegee Study of Untreated Syphilis in the Negro Male.”

The study initially involved 600 black men – 399 with syphilis, 201 who did not have the disease. The study was conducted without the benefit of patients’ informed consent. Researchers told the men they were being treated for “bad blood,” a local term used to describe several ailments, including syphilis, anemia, and fatigue. In truth, they did not receive the proper treatment needed to cure their illness. In exchange for taking part in the study, the men received free medical exams, free meals, and burial insurance. Although originally projected to last 6 months, the study actually went on for 40 years.

Doctor giving man a shot

What Went Wrong?

In July 1972, an Associated Press story about the Tuskegee Study caused a public outcry that led the Assistant Secretary for Health and Scientific Affairs to appoint an Ad Hoc Advisory Panel to review the study. The panel had nine members from the fields of medicine, law, religion, labor, education, health administration, and public affairs.

The panel found that the men had agreed freely to be examined and treated. However, there was no evidence that researchers had informed them of the study or its real purpose. In fact, the men had been misled and had not been given all the facts required to provide informed consent.

The men were never given adequate treatment for their disease. Even when penicillin became the drug of choice for syphilis in 1947, researchers did not offer it to the subjects. The advisory panel found nothing to show that subjects were ever given the choice of quitting the study, even when this new, highly effective treatment became widely used.

man walking down a dirt road

The Study Ends and Reparation Begins

The advisory panel concluded that the Tuskegee Study was “ethically unjustified”–the knowledge gained was sparse when compared with the risks the study posed for its subjects. In October 1972, the panel advised stopping the study at once. A month later, the Assistant Secretary for Health and Scientific Affairs announced the end of the Tuskegee Study.

In the summer of 1973, a class-action lawsuit was filed on behalf of the study participants and their families. In 1974, a $10 million out-of-court settlement was reached. As part of the settlement, the U.S. government promised to give lifetime medical benefits and burial services to all living participants. The Tuskegee Health Benefit Program (THBP) was established to provide these services. In 1975, wives, widows and offspring were added to the program. In 1995, the program was expanded to include health as well as medical benefits. The Centers for Disease Control and Prevention was given responsibility for the program, where it remains today in the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. The last study participant died in January 2004. The last widow receiving THBP benefits died in January 2009. There are 12 offspring currently receiving medical and health benefits.

Social Context: Technological Developments

Genetics, genomics, and epigenetics

Human Genome Project

Funded by National Institutes of Health

Mapped out 20,000 to 25,000 genes on the human genome

Significant effect on understanding health and illness

“Genetics,” “genomics,” and “epigenetics”

Genetics is the science of heredity, and genomics is the study of genomes—DNA sequences.

Epigenetics is a relatively new and important field of study: the examination of the causes of changes in phenotypes or gene expressions that are not explained by the underlying DNA sequence.

The Human Genome Project was a study funded by the National Institutes of Health in which the 20,000 to 25,000 genes on the human genome were mapped out. This took 13 years. The data from the Human Genome Project will have significant effect on our understanding of health and illness, as well as on predicting who is likely to develop certain conditions, and when.

Social Context: Technological Developments

Pharmacogenetics – the mechanisms and actions of medications can be determined by their genetic structures

For example, advances are being made in chemotherapy for certain cancers, such as leukemias and lymphomas, in which methylation that occurs at the gene level causes the expression of the genes to be aberrant, that is, to go wrong, leading to the development of malignant cell growth. Certain drugs used to treat these cancers are “hypomethylating” agents that reverse the increased or “hyper” methylation that is occurring in the cells’ genetic material.

Biomedical technology – complex machines or implantable devices used in patient care settings for a variety of reasons

Example, pacemakers, internal automated defibrillators, insulin pumps, artificial organs, and various invasive monitoring systems such as those used to measure intracranial pressure.

Implication: Nurses assume responsibility for monitoring the data generated from these machines and for assessing the safety and effectiveness of implantable equipment in relation to patient well-being.

The nurse is called on to react to the data and revise the plan of care.

Do not forget that there is a “human in there” under all of the lines and monitors.

Pharmacogenetics – mechanism of action can be determined by genetic structures

skilled nursing

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