Nursing Role and Scope

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Parker Rights & Media Specialist: Wes DeShano Media Development Editor: Shannon Sheehan Cover Image: © robertiez/iStock/Getty Images Plus/Getty Printing and Binding: RR Donnelley Cover Printing: RR Donnelley Library of Congress Cataloging-in-Publication Data Role development in professional nursing practice / [edited by] Kathleen Masters. – Fourth edition. p. ; cm. Includes bibliographical references and index. ISBN 978-1-284-07832-9 (pbk.) I. Masters, Kathleen, editor. [DNLM: 1. Nursing–standards. 2. Nursing–trends. 3. Nurse’s Role. 4. Philosophy, Nursing. 5. Professional Practice. WY 16] RT82 610.73–dc23 2015022040 6048 Printed in the United States of America 19 18 17 16 15 10 9 8 7 6 5 4 3 2 1 8 Dedication This book is dedicated to my Heavenly Father and to my loving family: my husband, Eddie, and my two daughters, Rebecca and Rachel. Words cannot express my appreciation for their ongoing encouragement and support throughout my career. 9 CONTENTS Preface Contributors UNIT I: FOUNDATIONS OF PROFESSIONAL NURSING PRACTICE 1 A History of Health Care and Nursing Karen Saucier Lundy and Kathleen Masters Classical Era Middle Ages The Renaissance The Dark Period of Nursing The Industrial Revolution And Then There Was Nightingale… Continued Development of Professional Nursing in the United Kingdom The Development of Professional Nursing in Canada The Development of Professional Nursing in Australia Early Nursing Education and Organization in the United States The Evolution of Nursing in the United States: The First Century of Professional Nursing The New Century International Council of Nurses Conclusion References 2 Frameworks for Professional Nursing Practice Kathleen Masters 10 Overview of Selected Nursing Theories Nurse of the Future: Nursing Core Competencies Overview of Selected Non-Nursing Theories Relationship of Theory to Professional Nursing Practice Conclusion References 3 Philosophy of Nursing Mary W. Stewart Philosophy Early Philosophy Paradigms Beliefs Values Developing a Personal Philosophy of Nursing Conclusion References 4 Foundations of Ethical Nursing Practice Janie B. Butts and Karen L. Rich Ethics Ethical Theories and Approaches Professional Ethics and Codes Ethical Analysis and Decision Making in Nursing Conclusion References 5 Social Context of Professional Nursing Mary W. Stewart, Katherine Elizabeth Nugent, Rowena W. Elliott, and 11 Kathleen Masters Nursing’s Social Contract with Society Public Image of Nursing The Gender Gap Changing Demographics and Cultural Competence Access to Health Care Societal Trends Trends in Nursing Conclusion References 6 Education and Socialization to the Professional Nursing Role Kathleen Masters and Melanie Gilmore Professional Nursing Roles and Values The Socialization (or Formation) Process Facilitating the Transition to Professional Practice Conclusion References 7 Advancing and Managing Your Professional Nursing Career Mary Louise Coyne and Cynthia Chatham Nursing: A Job or a Career? Trends That Impact Nursing Career Decisions Showcasing Your Professional Self Mentoring Education and Lifelong Learning Professional Engagement Expectations for Your Performance 12 Taking Care of Self Conclusion References UNIT II: PROFESSIONAL NURSING PRACTICE AND THE MANAGEMENT OF PATIENT CARE 8 Patient Safety and Professional Nursing Practice Jill Rushing and Kathleen Masters Patient Safety Critical Thinking, Clinical Judgment, and Clinical Reasoning in Nursing Practice Conclusion References 9 Quality Improvement and Professional Nursing Practice Kathleen Masters Healthcare Quality Measurement of Quality The Role of the Nurse in Quality Improvement Conclusion References Professional Nursing Practice 10 Evidence-Based Kathleen Masters Evidence-Based Practice: What Is It? Barriers to Evidence-Based Practice Promoting Evidence-Based Practice Searching for Evidence Evaluating the Evidence Implementation Models for Evidence-Based Practice 13 Conclusion References 11 Patient-Centered Care and Professional Nursing Practice Kathleen Masters Dimensions of Patient-Centered Care Communication as a Strategy to Support Patient-Centered Care Patient Education as a Strategy to Support Patient-Centered Care Evaluation of Patient-Centered Care Conclusion References in Professional Nursing Practice 12 Informatics Kathleen Masters and Cathy K. Hughes Informatics: What Is It? The Impact of Legislation on Health Informatics Nursing Informatics Competencies Basic Computer Competencies Information Literacy Information Management Current and Future Trends Conclusion References and Collaboration in Professional Nursing Practice 13 Teamwork Sharon Vincent and Kathleen Masters Healthcare Delivery System Nursing Models of Patient Care Roles of the Professional Nurse 14 Interprofessional Teams and Healthcare Quality and Safety Interprofessional Collaborative Practice Domains Interprofessional Team Performance and Communication Conclusion References Issues in Professional Nursing Practice 14 Ethical Janie B. Butts and Karen L. Rich Relationships in Professional Practice Moral Rights and Autonomy Social Justice Death and End-of-Life Care Conclusion References and the Professional Nurse 15 Law Kathleen Driscoll, Kathleen Masters, and Evadna Lyons The Sources of Law Classification and Enforcement of the Law Nursing Scope and Standards Malpractice and Negligence Nursing Licensure Professional Accountability Conclusion References Appendix A Standards of Professional Nursing Practice Appendix B Provisions of Code of Ethics for Nurses Appendix C The ICN Code of Ethics for Nurses 15 Glossary Index 16 PREFACE Although the process of professional development is a lifelong journey, it is a journey that begins in earnest during the time of initial academic preparation. The goal of this book is to provide nursing students with a road map to help guide them along their journey as a professional nurse. This book is organized into two units. The chapters in the first unit focus on the foundational concepts that are essential to the development of the individual professional nurse. The chapters in Unit II address issues related to professional nursing practice and the management of patient care, specifically in the context of quality and safety. In the fourth edition, the chapter content is conceptualized, when applicable, around nursing competencies, professional standards, and recommendations from national groups, such as Institute of Medicine reports. The chapters included in Unit I provide the student nurse with a basic foundation in areas such as nursing history, theory, philosophy, ethics, socialization into the nursing role, and the social context of nursing. All chapters have been updated, and several chapters in Unit I have been expanded in this edition. Revisions to the chapter on nursing history include the addition of contributions of prominent nurses and achievements related to nursing in the United Kingdom, Canada, and Australia. The theory chapter now includes additional nursing theorists as well as a brief overview of several non-nursing theories frequently used in nursing research and practice. The social context of nursing chapter now incorporates not only societal trends, but also trends in nursing practice and education. The chapter related to professional career development in nursing has been completely rewritten for this edition. The chapters in Unit II are more directly related to patient care management. In the fourth edition, Unit II chapter topics are presented in the context of quality and safety. Chapter topics include the role of the nurse in patient safety, the role of the nurse in quality improvement, evidence-based nursing practice, the role of the nurse in patient-centered care, informatics in nursing practice, the role of the nurse related to teamwork and collaboration, ethical issues in nursing practice, and the law as it relates to patient care and nursing. Most Unit II chapters have undergone major revisions with a refocus of the content on recommended nursing and healthcare competencies. The fourth edition continues to incorporate the Nurse of the Future: Nursing Core Competencies throughout each chapter. The Nurse of the Future: Nursing Core Competencies “emanate from the foundation of nursing knowledge” (Massachusetts Department of Higher Education, 2010, 17 p. 4) and are based on the American Association of Colleges of Nursing’s Essentials of Baccalaureate Education for Professional Nursing Practice, National League for Nursing Council of Associate Degree Nursing competencies, Institute of Medicine recommendations, Quality and Safety Education for Nurses (QSEN) competencies, and American Nurses Association standards, as well as other professional organization standards and recommendations. The 10 competencies included in the model are patient-centered care, professionalism, informatics and technology, evidencebased practice, leadership, systems-based practice, safety, communication, teamwork and collaboration, and quality improvement. Essential knowledge, skills, and attitudes (KSA) reflecting cognitive, psychomotor, and affective learning domains are specified for each competency. The KSA identified in the model reflect the expectations for initial nursing practice following the completion of a prelicensure professional nursing education program (Massachusetts Department of Higher Education, 2010, p. 4). 18 Source: Modified from Massachusetts Department of Higher Education. (2010). Nurse of the future: Nursing core competencies (p. 5). Retrieved from http://www.mass.edu/currentinit/documents/NursingCoreCompetencies.pdf The Nurse of the Future: Nursing Core Competencies graphic illustrates through the use of broken lines the reciprocal and continuous relationship between each of the competencies and nursing knowledge, that the competencies can overlap and are not mutually exclusive, and that all competencies are of equal importance. In addition, nursing knowledge is placed as the core in the graphic to illustrate that nursing knowledge reflects the overarching art and science of professional nursing practice (Massachusetts Department of Higher Education, 2010, p. 4). This new edition has competency boxes throughout the chapters that link examples of the KSA appropriate to the chapter content to Nurse of the Future: Nursing Core Competencies required of entry-level professional 19 nurses. The competency model in its entirety is available online at www.mass.edu/currentinit/documents/NursingCoreCompetencies.pdf. This new edition continues to use case studies, congruent with Benner, Sutphen, Leonard, and Day’s (2010) Carnegie Report recommendations that nursing educators teach for “situated cognition” using narrative strategies to lead to “situated action,” thus increasing the clinical connection in our teaching or that we teach for “clinical salience.” In addition, critical thinking questions are included throughout each chapter to promote student reflection on the chapter concepts. Classroom activities are also provided based on chapter content. Additional resources not connected to this text, but applicable to the content herein, include a toolkit focused on the nursing core competencies available at www.mass.edu/nahi/documents/ToolkitFirst%20Edition-May%202014-r1.pdf and teaching activities related to nursing competencies available on the QSEN website at www.qsen.org/teaching-strategies/. Although the topics included in this textbook are not inclusive of all that could be discussed in relationship to the broad theme of role development in professional nursing practice, it is my prayer that the subjects herein make a contribution to the profession of nursing by providing the student with a solid foundation and a desire to grow as a professional nurse throughout the journey that we call a professional nursing career. Let the journey begin. —Kathleen Masters References Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Massachusetts Department of Higher Education. (2010). Nurse of the future: Nursing core competencies. Retrieved from http://www.mass.edu/currentinit/documents/NursingCoreCompetencies.pdf 20 CONTRIBUTORS Janie B. Butts, PhD, RN University of Southern Mississippi College of Nursing Hattiesburg, Mississippi Cynthia Chatham, DSN, RN University of Southern Mississippi College of Nursing Long Beach, Mississippi Mary Louise Coyne, DNSc, RN University of Southern Mississippi College of Nursing Long Beach, Mississippi Kathleen Driscoll, JD, MS, RN University of Cincinnati College of Nursing Cincinnati, Ohio Rowena W. Elliott, PhD, RN, FAAN University of Southern Mississippi College of Nursing Hattiesburg, Mississippi Melanie Gilmore, PhD, RN University of Southern Mississippi College of Nursing Hattiesburg, Mississippi Cathy K. Hughes, DNP, RN University of Southern Mississippi College of Nursing Hattiesburg, Mississippi Karen Saucier Lundy, PhD, RN, FAAN Professor Emeritus University of Southern Mississippi College of Nursing Hattiesburg, Mississippi Evadna Lyons, PhD, RN East Central Community College School of Nursing Decatur, Mississippi Katherine Elizabeth Nugent, PhD, RN Dean, College of Nursing University of Southern Mississippi Hattiesburg, Mississippi Karen L. Rich, PhD, RN University of Southern Mississippi College of Nursing Long Beach, Mississippi 21 Jill Rushing, MSN, RN University of Southern Mississippi College of Nursing Hattiesburg, Mississippi Mary W. Stewart, PhD, RN Director of PhD Program University of Mississippi Medical Center School of Nursing Jackson, Mississippi Sharon Vincent, DNP, RN, CNOR University of North Carolina College of Nursing Charlotte, North Carolina 22 UNIT I Foundations of Professional Nursing Practice 23 CHAPTER 1 A History of Health Care and Nursing Karen Saucier Lundy and Kathleen Masters 24 Learning Objectives After completing this chapter, the student should be able to: 1. Identify social, political, and economic influences on the development of professional nursing practice. 2. Identify important leaders and events that have significantly affected the development of professional nursing practice. 25 Key Terms and Concepts » Greek era » Roman era » Deaconesses » Florence Nightingale » Reformation » Chadwick Report » Shattuck Report » William Rathbone » Ethel Fenwick » Jeanne Mance » Mary Agnes Snively » Goldmark Report » Brown Report » Isabel Hampton Robb » American Nurses Association (ANA) » Lavinia Lloyd Dock » American Journal of Nursing (AJN) » Margaret Sanger » Lillian Wald » Jane A. Delano » Annie Goodrich » Mary Brewster » Henry Street Settlement » Elizabeth Tyler » Jessie Sleet Scales » Dorothea Lynde Dix » Clara Barton 26 » Frontier Nursing Service » Mary Breckinridge » Mary D. Osborne » Frances Payne Bolton » International Council of Nurses (ICN) Although no specialized nurse role per se developed in early civilizations, human cultures recognized the need for nursing care. The truly sick person was weak and helpless and could not fulfill the duties that were normally expected of a member of the community. In such cases, someone had to watch over the patient, nurse him or her, and provide care. In most societies, this nurse role was filled by a family member, usually female. As in most cultures, the childbearing woman had special needs that often resulted in a specialized role for the caregiver. Every society since the dawn of time had someone to nurse and take care of the mother and infant around the childbearing events. In whatever form the nurse took, the role was associated with compassion, health promotion, and kindness (Bullough & Bullough, 1978). 27 Classical Era More than 4,000 years ago, Egyptian physicians and nurses used an abundant pharmacological repertoire to cure the ill and injured. The Ebers Papyrus lists more than 700 remedies for ailments ranging from snakebites to puerperal fever (Kalisch & Kalisch, 1986). Healing appeared in the Egyptian culture as the successful result of a contest between invisible beings of good and evil (Shryock, 1959). Around 1000 B.C., the Egyptians constructed elaborate drainage systems, developed pharmaceutical herbs and preparations, and embalmed the dead. The Hebrews formulated an elaborate hygiene code that dealt with laws governing both personal and community hygiene, such as contagion, disinfection, and sanitation through the preparation of food and water. The Jewish contribution to health is greater in sanitation than in their concept of disease. Garbage and excreta were disposed of outside the city or camp, infectious diseases were quarantined, spitting was outlawed as unhygienic, and bodily cleanliness became a prerequisite for moral purity. Although many of the Hebrew ideas about hygiene were Egyptian in origin, the Hebrews were the first to codify them and link them with spiritual godliness (Bullough & Bullough, 1978). Disease and disability in the Mesopotamian area were considered a great curse, a divine punishment for grievous acts against the gods. Experiencing illness as punishment for a sin linked the sick person to anything even remotely deviant. Not only was the person suffering from the illness, but he or she also was branded by all of society as having deserved it. Those who obeyed God’s law lived in health and happiness, and those who transgressed the law were punished with illness and suffering. The sick person then had to make atonement for the sins, enlist a priest or other spiritual healer to lift the curse, or live with the illness to its ultimate outcome (Bullough & Bullough, 1978). Nursing care by a family member or relative would be needed, regardless of the outcome of the sin, curse, disease-atonement-recovery, or death cycle. This logic became the basis for explanation of why some people “get sick and some don’t” for many centuries and still persists to some degree in most cultures today. The Greeks and Health In Greek mythology, the god of medicine, Asclepias, cured disease. One of his daughters, Hygeia, from whom we derive the word hygiene, was the goddess of preventive health and protected humans from disease. Panacea, Asclepias’ other daughter, was known as the all-healing “universal remedy,” and today her name is used to describe any ultimate cure-all in medicine. She 28 was known as the “light” of the day, and her name was invoked and shrines built to her during times of epidemics (Brooke, 1997). During the Greek era, Hippocrates of Cos emphasized the rational treatment of sickness as a natural rather than god-inflicted phenomenon. Hippocrates (460–370 B.C.) is considered the father of medicine because of his arrangements of the oral and written remedies and diseases, which had long been secrets held by priests and religious healers, into a textbook of medicine that was used for centuries (Bullough & Bullough, 1978). In Greek society, health was considered to result from a balance between mind and body. Hippocrates wrote a most important book, Air, Water and Places, which detailed the relationship between humans and the environment. This is considered a milestone in the eventual development of the science of epidemiology as the first such treatise on the connectedness of the web of life. This topic of the relationship between humans and their environment did not reoccur until the development of bacteriology in the late 1800s (Rosen, 1958). Perhaps the idea that most damaged the practice and scientific theory of medicine and health for centuries was the doctrine of the four humors, first spoken of by Empedocles of Acragas (493–433 B.C.). Empedocles was a philosopher and a physician, and as a result, he synthesized his cosmological ideas with his medical theory. He believed that the same four elements that made up the universe were found in humans and in all animate beings (Bullough & Bullough, 1978). Empedocles believed that man was a microcosm, a small world within the macrocosm, or external environment. The four humors of the body (blood, bile, phlegm, and black bile) corresponded to the four elements of the larger world (fire, air, water, and earth) (Kalisch & Kalisch, 1986). Depending on the prevailing humor, a person was sanguine, choleric, phlegmatic, or melancholic. Because of this strongly held and persistent belief in the connection between the balance of the four humors and health status, treatment was aimed at restoring the appropriate balance of the four humors through the control of their corresponding elements. Through manipulating the two sets of opposite qualities—hot and cold, wet and dry—balance was the goal of the intervention. Fire was hot and dry, air was hot and wet, water was cold and wet, and earth was cold and dry. For example, if a person had a fever, cold compresses would be prescribed; for a chill the person would be warmed. Such doctrine gave rise to faulty and ineffective treatment of disease that influenced medical education for many years (Taylor, 1922). Plato, in The Republic, details the importance of recreation, a balanced mind and body, nutrition, and exercise. A distinction was made among gender, class, and health as early as the Greek era; only males of the aristocracy could afford the luxury of maintaining a healthful lifestyle 29 (Rosen, 1958). In The Iliad, a poem about the attempts to capture Troy and rescue Helen from her lover Paris, 140 different wounds are described. The mortality rate averaged 77.6%, the highest as a result of sword and spear thrusts and the lowest from superficial arrow wounds. There was considerable need for nursing care, and Achilles, Patroclus, and other princes often acted as nurses to the injured. The early stages of Greek medicine reflected the influences of Egyptian, Babylonian, and Hebrew medicine. Therefore, good medical and nursing techniques were used to treat these war wounds: The arrow was drawn or cut out, the wound washed, soothing herbs applied, and the wound bandaged. However, in sickness in which no wound occurred, an evil spirit was considered the cause. The Greeks applied rational causes and cures to external injuries, while internal ailments continued to be linked to spiritual maladies (Bullough & Bullough, 1978). Roman Era During the rise and the fall of the Roman era (31 B.C.–A.D. 476), Greek culture continued to be a strong influence. The Romans easily adopted Greek culture and expanded the Greeks’ accomplishments, especially in the fields of engineering, law, and government. For Romans, the government had an obligation to protect its citizens, not only from outside aggression such as warring neighbors, but from inside the civilization, in the form of health laws. According to Bullough and Bullough (1978), Rome was essentially a “Greek cultural colony” (p. 20). Galen of Pergamum (A.D. 129–199), often known as the greatest Greek physician after Hippocrates, left for Rome after studying medicine in Greece and Egypt and gained great fame as a medical practitioner, lecturer, and experimenter. In his lifetime, medicine evolved into a science; he submitted traditional healing practices to experimentation and was possibly the greatest medical researcher before the 1600s (Bullough & Bullough, 1978). He was considered the last of the great physicians of antiquity (Kalisch & Kalisch, 1986). The Greek physicians and healers certainly made the most contributions to medicine, but the Romans surpassed the Greeks in promoting the evolution of nursing. Roman armies developed the notion of a mobile war nursing unit because their battles took them far from home where they could be cared for by wives and family. This portable hospital was a series of tents arranged in corridors; as battles wore on, these tents gave way to buildings that became permanent convalescent camps at the battle sites (Rosen, 1958). Many of these early military hospitals have been excavated by archaeologists along the banks of the Rhine and Danube Rivers. They had wards, recreation areas, baths, pharmacies, and even rooms for officers who needed a “rest 30 cure” (Bullough & Bullough, 1978). Coexisting were the Greek dispensary forms of temples, or the iatreia, which started out as a type of physician waiting room. These eventually developed into a primitive type of hospital, places for surgical clients to stay until they could be taken home by their families. Although nurses during the Roman era were usually family members, servants, or slaves, nursing had strengthened its position in medical care and emerged during the Roman era as a separate and distinct specialty. The Romans developed massive aqueducts, bathhouses, and sewer systems during this era. At the height of the Roman Empire, Rome provided 40 gallons of water per person per day to its 1 million inhabitants, which is comparable to our rates of consumption today (Rosen, 1958). 31 Middle Ages Many of the advancements of the Greco-Roman era were reversed during the Middle Ages (A.D. 476–1453) after the decline of the Roman Empire. The Middle Ages, or the medieval era, served as a transition between ancient and modern civilizations. Once again, myth, magic, and religion were explanations and cures for illness and health problems. The medieval world was the result of a fusion of three streams of thought, actions, and ways of life—Greco-Roman, Germanic, and Christian—into one (Donahue, 1985). Nursing was most influenced by Christianity with the beginning of deaconesses, or female servants, doing the work of God by ministering to the needs of others. Deacons in the early Christian churches were apparently available only to care for men, while deaconesses cared for the needs of women. The role of deaconesses in the church was considered a forward step in the development of nursing and in the 1800s would strongly influence the young Florence Nightingale. During this era, Roman military hospitals were replaced by civilian ones. In early Christianity, the Diakonia, a kind of combination outpatient and welfare office, was managed by deacons and deaconesses and served as the equivalent of a hospital. Jesus served as the example of charity and compassion for the poor and marginal of society. Communicable diseases were rampant during the Middle Ages, primarily because of the walled cities that emerged in response to the paranoia and isolation of the populations. Infection was next to impossible to control. Physicians had little to offer, deferring to the church for management of disease. Nursing roles were carried out primarily by religious orders. The oldest hospital (other than military hospitals in the Roman era) in Europe was most likely the Hôtel-Dieu in Lyons, France, founded about 542 by Childebert I, king of France. The Hôtel-Dieu in Paris was founded around 652 by Saint Landry, bishop of Paris. During the Middle Ages, charitable institutions, hospitals, and medical schools increased in number, with the religious leaders as caregivers. The word hospital, which is derived from the Latin word hospitalis, meaning service of guests, was most likely more of a shelter for travelers and other pilgrims as well as the occasional person who needed extra care (Kalisch & Kalisch, 1986). Early European hospitals were more like hospices or homes for the aged, sick pilgrims, or orphans. Nurses in these early hospitals were religious deaconesses who chose to care for others in a life of servitude and spiritual sacrifice. Black Death During the Middle Ages, a series of horrible epidemics, including the Black 32 Death or bubonic plague, ravaged the civilized world (Diamond, 1997). In the 1300s, Europe, Asia, and Africa saw nearly half their populations lost to the bubonic plague. Worldwide, more than 60 million deaths were attributed to this horrible plague. In some parts of Europe, only one-fourth of the population survived, with some places having too few survivors alive to bury the dead. Families abandoned sick children and the sick were often left to die alone (Cartwright, 1972). Nurses and physicians were powerless to avert the disease. Black spots and tumors on the skin appeared, and petechiae and hemorrhages gave the skin a darkened appearance. There was also acute inflammation of the lungs, burning sensations, unquenchable thirst, and inflammation of the entire body. Hardly anyone afflicted survived the third day of the attack. So great was the fear of contagion that ships carrying bodies of infected persons were set to sail without a crew to drift from port to port through the North, Black, and Mediterranean Seas with their dead passengers (Cohen, 1989). Medieval people knew that this disease was in some way communicable, but they were unsure of the mode of transmission (Diamond, 1997); hence the avoidance of victims and a reliance on isolation techniques. During this time, the practice of quarantine in city ports was developed as a preventive measure that is still used today (Bullough & Bullough, 1978; Kalisch & Kalisch, 1986). 33 The Renaissance During the rebirth of Europe, political, social, and economic advances occurred along with a tremendous revival of learning. Donahue (1985) contends that the Renaissance has been “viewed as both a blessing and a curse” (p. 188). There was a renewed interest in the arts and sciences, which helped advance medical science (Boorstin, 1985; Bullough & Bullough, 1978). Columbus and other explorers discovered new worlds, and belief in a sun-centered rather than an Earth-centered universe was promoted by Copernicus (1473–1543). Sir Isaac Newton’s (1642–1727) theory of gravity changed the world forever. Gunpowder was introduced, and social and religious upheavals resulted in the American and French Revolutions at the end of the 1700s. In the arts and sciences, Leonardo da Vinci, known as one of “the greatest geniuses of all time,” made a number of anatomic drawings based on dissection experiences. These drawings have become classics in the progression of knowledge about the human anatomy. Many artists of this time left an indelible mark and continue to exert influence today, including Michelangelo, Raphael, and Titian (Donahue, 1985). The Reformation Religious changes during the Renaissance influenced nursing perhaps more than any other aspect of society. Particularly important was the rise of Protestantism as a result of the reform movements of Martin Luther (1483– 1546) in Germany and John Calvin (1509–1564) in France and Switzerland. Although the various sects were numerous in the Protestant movement, the agreement among the leaders was almost unanimous on the abolition of the monastic or cloistered career. The effects on nursing were drastic: Monasticaffiliated institutions, including hospitals and schools, were closed, and orders of nuns, including nurses, were dissolved. Even in countries where Catholicism flourished, royal leaders seized monasteries frequently. Religious leaders, such as Martin Luther, who led the Reformation in 1517, were well aware of the lack of adequate nursing care as a result of these sweeping changes. Luther advocated that each town establish something akin to a “community chest” to raise funds for hospitals and nurse visitors for the poor (Dietz & Lehozky, 1963). Thus, the closures of the monasteries eventually resulted in the creation of public hospitals where laywomen performed nursing care. It was difficult to find laywomen who were willing to work in these hospitals to care for the sick, so judges began giving prostitutes, publically intoxicated women, and poverty-stricken women the option of going to jail, going to the poorhouse, or working in the 34 public hospital. Unlike the sick wards in monasteries, which were generally considered to be clean and well managed, the public hospitals were filthy, disorganized buildings where people went to die while being cared for by laywomen who were not trained, motivated, or qualified to care for the sick (Sitzman & Judd, 2014a). In England, where there had been at least 450 charitable foundations before the Reformation, only a few survived the reign of Henry VIII, who closed most of the monastic hospitals (Donahue, 1985). Eventually, Henry VIII’s son, Edward VI, who reigned from 1547 to 1553, endowed some hospitals, namely, St. Bartholomew’s Hospital and St. Thomas’ Hospital, which would eventually house the Nightingale School of Nursing later in the 1800s (Bullough & Bullough, 1978). 35 The Dark Period of Nursing The last half of the period between 1500 and 1860 is widely regarded as the “dark period of nursing” because nursing conditions were at their worst (Donahue, 1985). Education for girls, which had been provided by the nuns in religious schools, was lost. Because of the elimination of hospitals and schools, there was no one to pass on knowledge about caring for the sick. As a result, the hospitals were managed and staffed by municipal authorities; women entering nursing service often came from illiterate classes, and even then, there were too few to serve (Dietz & Lehozky, 1963). The lay attendants who filled the nursing role were illiterate, rough, inconsiderate, and often immoral and alcoholic. Intelligent women and men could not be persuaded to accept such a degraded and low-status position in the offensive municipal hospitals of London. Nursing slipped back into a role of servitude as menial, low-status work. According to Donahue (1985), when a woman could no longer make it as a gambler, prostitute, or thief, she might become a nurse. Eventually, women serving jail sentences for crimes such as prostitution and stealing were ordered to care for the sick in the hospitals instead of serving their sentences in the city jail (Dietz & Lehozky, 1963). The nurses of this era took bribes from clients, became inappropriately involved with them, and survived the best way they could, often at the expense of their assigned clients. Nursing had, during this era, virtually no social standing or organization. Even Catholic sisters of the religious orders throughout Europe “came to a complete standstill” professionally because of the intolerance of society (Donahue, 1985, p. 231). Charles Dickens, in Martin Chuzzlewit (1844), created the enduring characters of Sairey Gamp and Betsy Prig. Sairey Gamp was a visiting nurse based on an actual hired attendant whom Dickens had met in a friend’s home. Sairey Gamp was hired to care for sick family members but was instead cruel to her clients, stole from them, and ate their rations; she was an alcoholic and has been immortalized forever as a reminder of the world in which Florence Nightingale came of age (Donahue, 1985). In the New World, the first hospital in the Americas, the Hospital de la Purísima Concepción, was founded some time before 1524 by Hernando Cortez, the conqueror of Mexico. The first hospital in the continental United States was erected in Manhattan in 1658 for the care of sick soldiers and slaves. In 1717, a hospita

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