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UNIT 1 Foundations of Community Health Nursing❂
You just left the home of a long-time client who is con- cerned about a new family who just moved into the building where she lives. The family of six lives in an apartment with barely enough room for two. After years in this neighborhood, you are well aware of the high rents charged for apartments with peeling paint, rodents, and garbage all around the build- ings. Your client is concerned that the young mother looks“worn out” and coughs all the time. She said she tried to help, but the family doesn’t speak much English. She describes four young children all under the age of about 5.
She’s never seen the husband, but you know that most of the men in this neighborhood leave early in the morning to try to get some day work, so you are not surprised. You assure your client that you will do what you can to help her new neighbors and thank her for being such a kind person. Thinking about how you will prepare for the visit to the family who doesn’t even expect you, your thoughts are racing. At the top of your list is trying to find someone who speaks their language; you only know a few words. You suspect without even seeing the mother what the cough means, although you hope you are wrong. Then you think about the four young children living so close together and creating so much work for a woman who isn’t well. The husband may want to help his wife more, but if he doesn’t work, they can’t get by. You wonder if he has the cough too.
As you read this scenario, what picture did you have in your mind? What language did this family speak? What dis- ease did this young mother likely have? Now, think about when this event might have occurred. If you thought it was now, it certainly could be, but this scenario was actually set in the early 1900s. This family emigrated from Greece and had- n’t yet mastered the English language. The mother likely had consumption (the old name for tuberculosis). Because birth control information was not available to most women, she had no idea how to space out her pregnancies. The filthy and over- crowded housing, often called tenement housing, was typical of the time. The husband found work as he could. Few social services were available; no work, no food for the family, and no money to pay the rent. The family came to America with the hope of a new start, but what they found was in many ways worse than what they had left. At least at home in Greece, they had family and friends to count on; here, they were alone.
There were others from Greece who lived nearby, but it was- n’t the same. Life was hard, and they worried most about their children, wondering what the future could hold for them.
Community health nurses in the early 20th century had to deal with many of the same issues we face today. We thought for a long time that tuberculosis was a disease of the past; now clients with multidrug-resistant strains are becom- ing alarmingly more common. Poverty, communicable dis- eases, poor housing, lack of social services, and limited access to family planning information remain as challenges to improving the health of our populations. As a community health nurse, you will be facing similar challenges to those faced by nurses of the past. History is not always exciting, but without it we often fail to see where we need to go next.
The often misquoted saying by George Santayana (1863–1952), “Those who cannot remember the past are condemned to repeat it,” serves to caution us not to “forget”
our heritage (Kaplin, 1992, p. 588). As you read through this chapter, think about how your practice has been shaped by the hard work of the nurses who went before.
This chapter examines the international roots of com- munity health nursing as a specialty, exploring the historical and philosophical foundations that undergird the dynamic nature of its practice. The chapter traces community health nursing’s historical development, highlighting the contribu- tions of several nursing leaders, and examining the global societal influences that shaped early and evolving commu- nity health nursing practice. The final section of the chapter describes the academic and advanced professional prepara- tion required of community health nurses today. Nursing’s past influences its present, and both guide the future of com- munity health nursing in the 21st century.
HISTORICAL DEVELOPMENT OF
CHAPTER 2 History and Evolution of Community Health Nursing
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27about the practice emphasis, not the title. There are still nurses in practice who use the title public health nurse, in addition to those called community health nurses; some even use the title community/public health nurse. Whether by cus- tom, preference, or established employment title, nurses call themselves by many professional titles. It is important to rec- ognize that the work of the nurse is, as it always has been, to improve the health of the community.
Early Home Care Nursing (Before Mid-1800s)
The prototype of community-based nursing can be seen within the historical development of home-care nursing. For many centuries, the sick were tended at home by female family members and friends. In fact, in 1837, Farrar (p. 57) reminded women, “You may be called upon at any moment to attend upon your parents, your brothers, your sisters, or your companions.” The focus of this care was to reduce suf- fering and promote healing.
The Origins of Early Nursing
The early roots of home-care nursing began with religious and charitable groups. Even emergency care was provided.
In 1244, a group of monks in Florence, Italy, known as the Misericordia provided first-aid care for accident victims on a 24-hour basis. Another example is the Knights Hospi- talers, who were warrior monks in Western Europe. They protected and cared for pilgrims on their way to Jerusalem (“Men, monasteries, wars, and wards,” 2001). These and other men’s contributions to the early practice of nursing have been long overlooked. Further, the lack of attention to these early works “perpetuates the notion of men nurses as anomalies” (Evans, 2004, p. 321).
Medieval times saw the development of various institu- tions devoted to the sick, including hospitals and nursing orders. In England, the Elizabethan Poor Law, written in 1601, provided medical and nursing care to the poor and disabled. St. Frances De Sales organized the Friendly Visitor Volunteers in the early 1600s in France. This association was directed by Madame de Chantel and assisted by wealthy women who cared for the sick poor in their homes (Dolan, 1978). In Paris in 1617, St. Vincent de Paul started the Sisters of Charity, an organization composed of nuns and lay women dedicated to serving the poor and needy. The ladies and sisters, under the supervision of Mademoiselle Le Gras in 1634, promoted the goal of teaching people to help them- selves as they visited the sick in their homes. In their empha- sis on preparing nurses and supervising nursing care, as well as determining causes and solutions for clients’ problems, the Sisters of Charity laid a foundation for modern commu- nity health nursing (Bullough & Bullough, 1978).
Unfortunately, the years that followed these accomplish- ments marked a serious setback in the status of nursing and care of the sick. From the late 1600s to the mid-1800s, the social upheaval after the Reformation caused a decline in the number of religious orders, with subsequent curtailing of nursing care for the sick poor. Babies continued to be deliv- ered at home by self-declared midwives, most of whom had little or no training. Concern over high maternal mortality rates prompted efforts to better prepare midwives and medical
students. One midwifery program was begun in Paris in 1720, and another in London by Dr. William Smellie in 1741 (Bul- lough & Bullough, 1978).
The Industrial Revolution created additional problems;
among them were epidemics, high infant mortality, occupa- tional diseases and injuries, and increasing mental illness in both Europe and America. Hospitals were built in larger cities, and dispensaries were developed to provide greater access to physicians. However, disease was rampant; mor- tality rates were high; and institutional conditions, espe- cially in prisons, hospitals, and “asylums” for the insane, were deplorable. The sick and afflicted were kept in filthy rooms without adequate food, water, cover, or care for their physical and emotional needs (Bullough & Bullough, 1978). Reformers such as John Howard, an Englishman who investigated the spread of disease in hospitals in 1789 (Kalisch & Kalisch, 2004), revealed serious needs that would not be addressed until much later (Bullough & Bul- lough, 1978).
Both Catholic and Anglican religious nursing orders, although few in number, continued the work of caring for the sick poor in their homes. For example, in 1812, the Sisters of Mercy organized in Dublin to provide care for the sick at home. With the status of women at an all-time low, often only the least respectable women pursued nursing. In 1844, in his novel Martin Chuzzlewit, Charles Dickens (1910) portrayed the nurse Sairy Gamp as an unschooled and slovenly drunk- ard, reflecting society’s view of nursing at the time. It was in the midst of these deplorable conditions and in response to them that Florence Nightingale began her work.
The Early Nightingale Years
Much of the foundation for modern community health nursing practice was laid through Florence Nightingale’s remarkable accomplishments (Figure 2.1). She has been referred to as a reformer, a reactionary, and a researcher (Palmer, 2001). Born in 1820 into a wealthy English family, her extensive travel, excellent education—including training at the first school for nurses in Kaiserwerth, Germany—and determination to serve the needy resulted in major reforms and improved status for nursing. Her work during the Crimean War (1854–1856) with the wounded in Scutari is well documented (Florence Nightin- gale Museum Trust, 1997; Woodham-Smith, 1951). Condi- tions in the military hospitals during the war were unspeak- able. Thousands of sick and wounded men lay in filth, without beds, clean coverings, food, water, or laundry facilities. Flo- rence Nightingale organized competent nursing care and established kitchens and laundries that resulted in hundreds of lives being saved. Her work further demonstrated that capable nursing intervention could prevent illness and improve the health of a population at risk—precursors to modern commu- nity health nursing practice. Her subsequent work for health reform in the military was supported by implementing another public health strategy: the use of biostatistics. Through metic- ulously gathered data and statistical comparisons, Miss Nightingale demonstrated that military mortality rates, even in peacetime, were double those of the civilian population because of the terrible living conditions in the barracks. This work led to important military reforms.
Miss Nightingale’s concern for populations at risk included a continuing interest in the population of the sick at
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home. Her book, Notes on Nursing: What It Is, and What It Is Not, published in England in 1859, was written to improve nursing care in the home. It was also during this period that Nightingale clarified nursing as a woman’s occupation (Evans, 2004). This gender distinction in nursing was due more to the culture of the times than as a direct exclusion of men from the practice; it was consistent with social norms of that period.
Florence Nightingale also became a skillful lobbyist for health care reform. Her exemplary influence on English politics and policy improved the quality of existing health care and set standards for future practice. Furthermore, she demonstrated how population-focused nursing works.
In her work to help establish the first nonreligious school for nurses in 1860 at St. Thomas Hospital in London, she promoted a standard for proper education and supervi- sion of nurses in practice, known as the Nightingale Model.
Principles she wrote about in Notes on Nursing relate directly to her early education and the notions held by Hip- pocrates in ancient Greece, which she had studied for years.
Specifically, her concern with the environment of patients, the need for keen observation, the focus on the whole patient rather than the disease, and the importance of assisting nature to bring about a cure all reflect Hippocrates’ teach- ings (Nightingale, 1859/1969; Palmer, 2001).
Another great nurse and healer in her own right was Mary Seacole (1805–1881), who has been called the “Black Nightin- gale.” She was the daughter of a well-respected “doctress” who practiced Creole or Afro-Caribbean medicine in Jamaica, and began helping her mother at an early age. Spending many years developing her skills, she helped populations who experienced tropical diseases, especially cholera, in Central America, Panama, and the Caribbean. She attempted, through many for- mal channels, to join Florence Nightingale in Scutari, but was rejected again and again. Undaunted, she went to the Crimea on her own to open a hotel for sick and convalescing soldiers,
where she met Miss Nightingale and many of the troops she had cared for in Jamaica. Many of the military commanders sought her out for her knowledge of healing, and she was affectionately known by the troops as “Mother Seacole.” After the war and into her old age, she continued to provide nursing care in London and when visiting Jamaica. She focused her caregiving among high-risk clients of the day and did so in an innovative, entrepreneurial manner unique for women, espe- cially for women of color in the 1800s (Florence Nightingale Museum Trust, 1997).
District Nursing (Mid-1800s to 1900) Nightingale’s Continued Influence
The next stage in the development of community health nurs- ing was the formal organization of visiting nursing, or district nursing. In 1859, William Rathbone, an English philanthro- pist, became convinced of the value of home nursing as a result of private care given to his wife. He employed Mary Robinson, the nurse who had cared for his wife, to visit the sick poor in their homes and teach them proper hygiene to prevent illness. The need was so great that it soon became evident that more nurses were needed. In 1861, with Florence Nightingale’s help and advice, Rathbone opened a training school for nurses connected with the Royal Liverpool Infir- mary and established a visiting nurse service for the sick poor in Liverpool. Florence Lees, a graduate of the Nightingale School, was appointed first Superintendent-General of the District Nursing System (Mowbray, 1997). As the service grew, visiting nurses were assigned to districts in the city—
hence the name, district nursing. Subsequently, other British cities also developed district nursing training and services. An example is the Nurse Training Institution for district nurses, founded in Manchester in 1864. Privately financed, the nurses were trained and then “dispensed food and medicine” to the sick poor in their homes; they were “closely supervised by various middle and upper class women who collected the nec- essary supplies” (Bullough & Bullough, 1978, p. 143).
Although Florence Nightingale is best remembered for her professionalization of nursing, she had a full under- standing of the need for community health nursing. This was documented in her writings and recorded conversations:
Hospitals are but an intermediate stage of civilisation. At present hospitals are the only place where the sick poor can be nursed, or, indeed often the sick rich. But the ultimate object is to nurse all sick at home. (Nightingale, 1876)
The aim of the district nurse is to give first-rate nursing to the sick poor at home. (Nightingale, 1876 [cited in Mow- bray, 1997, p. 24])
The health visitor must create a new profession for women. (conversation with Frederick Verney, 1891 [cited in Mowbray, 1997, p. 25])
For years, Miss Nightingale studied the social and eco- nomic conditions of India (Nightingale, 1864). The plight of the poor and ill in India led her to become involved with Frederick Verney in a pioneering “health at home” project in England in 1892. She wrote a series of papers on the need for “home missioners” and “health visitors,” endorsing the view that prevention was better than cure (Mowbray, 1997).
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UNIT 1 Foundations of Community Health NursingF I G U R E 2.1 Florence Nightingale’s concern for populations at risk, as well as her vision and successful efforts at health reform, pro- vided a model for community health nursing today.
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CHAPTER 2 History and Evolution of Community Health Nursing
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29DISPLAY 2.1
1873 First Nightingale-model nursing school established in the U.S. at Bellevue Hospital
1877 Francis Root—First Public Health Nurse hired by the Women’s Branch of the New York Mission 1885 Visiting Nurse Association established in Buffalo, New York
1886 Visiting Nurse Associations established in Philadelphia and Boston
1893 Lillian Wald and Mary Brewster organize a visiting nurses service for the poor in New York, which would be named the Henry Street Settlement in 1906