Nursing Evolution?

The word “evolution” suggests progress over time. So when we speak of the “evolution of nursing” we’re talking about progress in the profession over time; but the idea of progress is subjective, isn’t it? What one nurse views as a step forward, another might view as a few steps backwards and vice versa.

For example, Florence Nightingale is often lauded in nursing culture as the singular person who established nursing as a distinct art and science which propelled it into becoming a profession. Up to her time, nurses served only as subordinates to doctors, taking their orders and doing their bidding largely without question. Nightingale, according to Black, met with opposition from this all-male establishment in improving the lot of the British soldiers during the Crimean War, and “Armed with an excellent education in statistics, Nightingale collected very detailed data on morbidity and mortality of the soldiers in Scutari. Using this supportive evidence, she effectively argued the case for reform…” (Black, 2014, p. 25). I do not wish here to question that Nightingale’s work marked a turning point in how patients were cared for with positive outcomes, but does establishing nursing practice using only the language of science to describe its intervention and outcome criteria to be viewed only as progressive? What was lost as a result of this change? Scientific reasoning very much relies on physical evidence, experimentation, and hard numbers in generating what it counts as knowledge; but what about the knowledge lost when only hard data are accepted? What about the knowledge of the subjective experience of suffering from an illness, or interacting and reacting to treatment, or the dynamics introduced by other subjectivities such as the physicians, nurses, family and other people in the patients’ lives? This is “metaphysical reductionism which means ‘what is gained on the one hand is lost on the other’” (Pitre & Myrick, 2007, p. 75) or one step forward and one step back. Add to this Evans’ observation that “the emphasis placed on nursing as a science strategically played down its caring and feminine image…” and furthered “the stereotype of men as rational technocrats who make ‘naturally’ good leaders” (2004, pp. 325-326) which perpetuated the stereotype that women are irrational and naturally poor leaders.  I don’t mean to suggest here that Nightingale’s efforts didn’t result in a positive step forward in nursing science. I only mean to suggest that Nightingale is largely responsible for the existence of the concept of “nursing science” and to show that this has had both positive and negative outcomes.

Another example is the move towards state licensure. This step is presented as a step forward for the nursing profession; but what does the possession of this license really tell one? Does is say anything about how well that particular person is likely to do as a practicing nurse or does it say that this person is adept at taking written tests? Licenses depend on written tests for their dispensation. Written tests privilege those who are better at manipulating and understanding the written word. People who are better at manipulating and understanding the written word are privileged by an educational system which tends to favor one learning style over others, a learning style, historically, more likely to be used by an economically and racially privileged class. I wonder how many potentially great nurses were excluded from the profession because they could not pass the NCLEX-RN?

Black refers to the rise of hospitals during the years immediately following World War Two as a result of the passing of the Hill-Burton Act in 1946 (2014). I’m not certain why this explosion in hospitals was deemed necessary. Perhaps more people were living in cities than in rural areas; maybe it was the burgeoning population called the “baby boom” which caused the building of these facilities. Whatever the reason or combinations thereof, it had both positive and negative effects. Black lists hospitals as places where new nurses may gain stronger clinical and assessment skills (2014). As an employee of a large hospital, I can attest to other advantages such as having support staff readily available to help in the care of patients, answer questions and generally learn from. The negatives included “an acute shortage of nurses and increasingly difficult working conditions. Long hours, inadequate salaries, and increasing patient loads made many nurses unhappy with their jobs, and threats of strikes and collective bargaining ensued” (Black, 2014, p. 33).

The advent of Medicare and Medicaid in the 1960s is often viewed as a step forward for nursing “because the majority of the care for the sick was taking place in hospitals” (Black, 2014, p. 34) which depended on reimbursements from these programs making hospitals “the preferred place of employment for nurses” (Black, 2014, p. 34) and allowing for the rise of novel roles and opportunities (Black, 2014). While this is true, it is also true, in my experience,  that Medicare and Medicaid gives rise to shorter hospital stays for patients based on what these programs will pay for which may lead to discharge before patients are ready, which leads to hospital recidivism, and ultimately leads to higher health care costs-one step forward, two steps back.

The rise of telehealth as a result of the digital revolution of recent years offers nursing advantages and opportunities for new roles previously unheard of. Quick and immediate access to patient data in real time, the ability to assess patients via live-feed cameras from remote locations, the ability to transfer data to those parties involved in the care of the patient are just a few of the convenient changes that have come about. But, like my comments about the idea of NCLEX testing privileging certain people, the rise of technology and its pervasiveness in nursing practice also serves to exclude those who aren’t able to make the adjustment from old ways of doing things. This causes alienation for nurses, probably older nurses, which may cause them to seek to leave nursing, the result being an experience drain in the profession at a time when it sorely needs experience to teach and guide students entering the field and nurses new to it.


While I don’t find myself immediately informed by nursing theories in my daily practice, I see them bleeding into it all the same. As a psychiatric nurse, I am of course in debt to Hildegard Peplau. Her emphasis on the nurse-patient relationship (Black, 2014) in a therapeutic milieu pervades what I do at my job in establishing trust, attentive listening, active involvement by the patient in achieving his/her goals, and taking responsibility for his/her care. I find myself using her model unconsciously in my multiple roles as “counselor, resource, teacher, technical expert, surrogate, and leader” (Black, 2014, p. 276).

In my initial training as a nurse, my school used Sister Callista Roy’s Adaptation Model. I personally thought it was uninteresting and tedious (and still do) I can see its influence on nursing every day, especially on medical-surgical units where a patient’s “adaptation behavior and stimuli in the internal and external environments” (Black, 2014, p. 275) is used to formulate nursing diagnoses and care plans.

While not aware of my having used Leininger’s Theory of Culture Care Diversity and Universality, I nonetheless value its precepts in nursing practice. If nursing is based on the patient’s response to illness, then it is important for a nurse to plan “nursing care, recognizing the health beliefs and folk practices of the patient’s culture, as well as the culture of traditional health services” (Black, 2014, p. 278) to be not only respectful but also to encourage compliance for positive outcomes.



Black, B. P. (2014). Professional nursing concepts & challenges (7th ed.). St. Louis, MO: Elsevier Saunders.

Brennan, E. & Renear, A. (1991, January 10). 4.0879 responses: Voltaire; on humanist (3/43). Message posted to

Pitre, N. Y., & Myrick, F. (2007). A view of nursing epistemology through reciprocal interdependence: Towards a reflexive way of knowing. Nursing Philosophy, 8(2), 73-84. doi:10.1111/j.1466-769X.2007.00298.x


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