- • Pre-Nightingale Reforms
- • Florence Nightingale
- • Contemporary Developments
- • Nursing in India
This chapter looks at the pre-Nightingale reforms led by St. Vincent De Paul and Mile Le Gras, Elizabeth Fry. The second face of this chapter involves the life and work of Florence Nighingale who is the founder of Nursing and started a nursing school at St. Thomas Hospital. It includes her interest in India and her work at Military hospital and Sanitation. It also contains the contemporary developments which explain the discoveries of Pasteur, Lister and Kosch, and the relationship of nursing to hospital reform. The final face involves the modern day of nursing in India which explains the introduction and growth of nursing in India, developments of schools, examination and registration. It also includes a brief review of organization in India today.
(i) St. Vincent De Paul and Mile Le Gras: Vincent de Paul (24 April, 1581 – 27 September, 1660) was a priest of the Catholic Church who dedicated himself to serving the poor. He is venerated as a saint in the Catholic Church and the Anglican Communion. He was canonized in 1737. He was renowned for his compassion, humility, and generosity and is known as the Great Apostle of Charity.
Saint Louise de Marillac, DC, also Louise Le Gras (August 12, 1591-March 15, 1660) was the co-founder, with Saint Vincent de Paul, of the Daughters of Charity. She is venerated as a saint by the Roman Catholic Church.
Louise de Marillac and Vincent de Paul met around the time of Antoine's passing. Widowed and lacking financial means, she had to move. Vincent de Paul lived near her new dwelling. At first, he was reluctant to be her confessor, busy as he was with his Confraternities of Charity. Members were aristocratic ladies of charity who were helping him nurse the poor and look after neglected children, a real need of the day. But the ladies were busy with many of their own concerns and duties.
Over the next four years, Vincent and Louise communicated often through letters and personal meetings, with Vincent guiding Louise to greater balance in a life of moderation, peace and calm. In 1629, Vincent invited Louise to get involved in his work with the Confraternities of Charity.
She found great success in these endeavors. Then, in 1632, Louise made a spiritual retreat seeking inner guidance regarding her next step. Her intuition led her to understand that it was time to intensify her ministry with poor and needy persons, while still maintaining a deep spiritual life. Louise, at age 42, drawn to focus on mission, communicated this aspiration to Monsieur Vincent. By the end of 1633, he too had received the guidance needed for them to bring the Daughters of Charity into existence.
(ii) Elizabeth Fry: Elizabeth (Betsy) Fry (21 May 1780–12 October 1845), was an English prison reformer, social reformer and, as a Quaker, a Christian philanthropist. She has sometimes been referred to as the ‘angel of prisons’.
Fry was a major driving force behind new legislation to make the treatment of prisoners more humane, and she was supported in her efforts by the reigning monarch.
Prompted by a family friend, Stephen Grellet, Fry visited Newgate Prison. The conditions she saw they horrified her. The women's section was overcrowded with women and children, some of whom had not even received a trial. The prisoners did their own cooking and washing in the small cells in which they slept on straw.
She returned the following day with food and clothes for some prisoners. She was unable to further her work for nearly four years because of difficulties within the Fry family, including financial difficulties in the Fry bank. Fry returned in 1816 and was eventually able to found a prison school for the children who were imprisoned with their mothers. She began a system of supervision and required the women to sew and to read the Bible. In 1817 she helped found the Association for the Reformation of the Female Prisoners in Newgate. This led to the eventual creation of the British Ladies’ Society for Promoting the Reformation of Female Prisoners, widely described by biographers and historians as constituting the first ‘nationwide’ women's organization in Britain.
(12 May 1820 – 13 August 1910)
Florence Nightingale came to prominence while serving as a manager of nurses trained by her during the Crimean War, where she organized the tending to wounded soldiers. She gave nursing a highly favorable reputation and became an icon of Victorian culture, especially in the persona of ‘The Lady with the Lamp’ making rounds of wounded soldiers at night.
Some recent commentators have asserted Nightingale's achievements in the Crimean War were exaggerated by the media at the time, to satisfy the public's need for a hero. Nevertheless, critics agree on the decisive importance of her follow-up achievements in professionalizing nursing roles for women. In 1860, Nightingale laid the foundation of professional nursing with the establishment of her nursing school at St Thomas’ Hospital in London. It was the first secular nursing school in the world, now part of King's College London. The Nightingale Pledge taken by new nurses was named in her honor, and the annual International Nurses Day is celebrated around the world on her birthday. Her social reforms include improving health care for all sections of British society, advocating better hunger relief in India, helping to abolish prostitution laws that were over-harsh to women, and expanding the acceptable forms of female participation in the workforce.
Nightingale was a prodigious and versatile writer. In her lifetime, much of her published work was concerned with spreading medical knowledge. Some of her tracts were written in simple English so that they could easily be understood by those with poor literary skills. She also helped popularize the graphical presentation of statistical data. Much of her writing, including her extensive work on religion and mysticism, has only been published posthumously.
Florence Nightingale's most famous contribution came during the Crimean War, which became her central focus when reports got back to Britain about the horrific conditions for the wounded. On 21 October 1854, she and the staff of 38 women volunteer nurses that she trained, including her aunt Mai Smith, and 15 Catholic nuns (mobilized by Henry Edward Manning) were sent (under the authorization of Sidney Herbert) to the Ottoman Empire. Nightingale was assisted in Paris by her friend Mary Clarke. They were deployed about 295 nautical miles (546 km; 339 mi) across the Black Sea from Balaklava in the Crimea, where the main British camp was based.
Nightingale arrived early in November 1854 at Selimiye Barracks in Scutari (modern-day Üsküdar in Istanbul). Her team found that poor care for wounded soldiers was being delivered by overworked medical staff in the face of official indifference. Medicines were in short supply, hygiene was being neglected, and mass infections were common, many of them fatal. There was no equipment to process food for the patients.
After Nightingale sent a plea to The Times for a government solution to the poor condition of the facilities, the British Government commissioned Isambard Kingdom Brunel to design a prefabricated hospital that could be built in England and shipped to the Dardanelles. The result was Renkioi Hospital, a civilian facility that, under the management of Dr Edmund Alexander Parkes, had a death rate less than 1/10th that of Scutari.
Stephen Paget in the Dictionary of National Biography asserted that Nightingale reduced the death rate from 42% to 2%, either by making improvements in hygiene herself, or by calling for the Sanitary Commission. For example, Nightingale implemented handwashing and other hygiene practices in the war hospital in which she worked.
Nightingale still believed that the death rates were due to poor nutrition, lack of supplies, stale air and overworking of the soldiers. After she returned to Britain and began collecting evidence before the Royal Commission on the Health of the Army, she came to believe that most of the soldiers at the hospital were killed by poor living conditions. This experience influenced her later career, when she advocated sanitary living conditions as of great importance. Consequently, she reduced peacetime deaths in the army and turned her attention to the sanitary design of hospitals and the introduction of sanitation in working-class homes.
Foundation of First Nursing School
Friday, 15 June 1860
Florence Nightingale was a revered English nurse, writer and statistician. Nightingale chose to become a nurse over the popular role of wife and mother. Though her family was against it, they could not change her mind. She believed that she had been called by God to pursue a nursing career.
Nightingale gained popularity during the Crimean war where she cared for wounded soldiers. In 1860 she established a nursing school at St Thomas Hospital in London. It was the first professional nursing school in the world. The nursing school is now part of King's College London where nursing graduates take the Nightingale pledge, so named in her honor.
Interest in India: Sanitary Reform
After the Crimean War, Florence Nightingale persisted in researching the health conditions of British troops throughout the Empire. Undaunted by geographic limitations, she surveyed and publicized data that documented the mismanagement of living conditions and health care among the occupational forces on the Indian continent. Nightingale proposed widespread changes in the reporting of military health status and biostatistics, in sanitary engineering, and in self-care activities. With dogged persistence, she continued to gather follow-up data to measure the changing health status of soldiers in a land she never saw.
It begins with her work to establish the Royal Commission on the Sanitary State of the Army in India, for which she drafted questionnaires, analyzed returns, and did much of the final writing, going on to promote the implementation of its recommendations. In this volume a gradual shift of attention can be seen from the health of the army to that of the civilian population. Famine and epidemics were frequent and closely interrelated occurrences. To combat them, Nightingale recommended a comprehensive set of sanitary measures, and educational and legal reforms, to be overseen by a public health agency. Skillful in implementing the expertise, influence and power of others, she worked with her impressive network of well-placed collaborators, having them send her information and meet with her back in London. The volume includes Nightingale's work on the royal commission itself, related correspondence, numerous published pamphlets, articles and letters to the editor, and correspondence with her growing network of viceroys, governors of presidencies, and public health experts. Working with British collaborators, she began this work; over time Nightingale increased her contact with Indian nationals and promoted their work and associations.
(December 27, 1822 – September 28, 1895)
Louis Pasteur was a French chemist and microbiologist for his discoveries of the principles of vaccination, microbial fermentation and pasteurization. He is remembered for his remarkable breakthroughs in the causes and preventions of diseases, and his discoveries have saved countless lives ever since. He reduced mortality from puerperal fever, and created the first vaccines for rabies and anthrax. His medical discoveries provided direct support for the germ theory of disease and its application in clinical medicine. He is best known to the general public for his invention of the technique of treating milk and wine to stop bacterial contamination, a process now called pasteurization. He is regarded as one of the three main founders of bacteriology, together with Ferdinand Cohn and Robert Koch, and is popularly known as the ‘father of microbiology’.
(5 April 1827 – 10 February 1912)
Joseph Lister, 1st Baron Lister, known as Sir Joseph Lister, Bt., between 1883 and 1897, was a British surgeon and a pioneer of antiseptic surgery. By applying Louis Pasteur's advances in microbiology, he promoted the idea of sterile portable ports while working at the Glasgow Royal Infirmary. Lister successfully introduced carbolic acid (now known as phenol) to sterilize surgical instruments and to clean wounds, which led to a reduction in post-operative infections and made surgery safer for patients.
(11 December 1843 – 27 May 1910)
Robert Koch was a celebrated German physician and pioneering. The founder of modern bacteriology, he is known for his role in identifying the specific causative agents of tuberculosis, cholera, and anthrax and for giving experimental support for the concept of infectious disease. In addition to his trail-blazing studies on these diseases, Koch created and improved laboratory technologies and techniques in the field of microbiology, and made key discoveries in public health.
His research led to the creation of Koch's postulates, a series of four generalized principles linking specific microorganisms to specific diseases that remain today the ‘gold standard’ in medical microbiology. As a result of his groundbreaking research on tuberculosis, Koch received the Nobel Prize in Physiology or Medicine in 1905.
NURSING IN INDIA
Nursing in India is the practice of care for medical patients in that nation.
Its history indicates that the principles and practices of nursing are ancient. These ancient nursing practices are so clear, intelligent and scientific, that many of them might fit into any of the modern textbook. Prior to the 20th century, Indian nurses were usually young men, with women acting as midwives for assisting with childbirth. The acceptance of nursing as a profession in India was obstructed by the low status of women, the caste system, illiteracy and political unrest.
Nursing is the largest, the most diverse and one of the most respected among the health care professions. Nursing is a profession which focuses on protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human responses and advocacy while caring for individuals, families, communities and populations, assuming responsibility for the continuous care of the sick 24 × 7, the injured, the disabled and the dying.
Globally, health systems are experiencing major shifts in their structure, organization, functions and management. Globalization and the technological transformation of health sectors are creating an increasingly diverse yet interconnected world. Within this ever-changing milieu, nurses are faced with many challenges, each demanding valuable and self-motivated leadership and managerial abilities if they are to be addressed effectively.
Nurses are different from other health care providers by their approach to patient care and varied scope of practice. Professional nurses work both independently and in collaboration with other health care professionals. Nurses practice in a wide diversified practice areas with a different scope of practice and level of authority in each. Many nurses provide care within the ordering scope of physicians, and this traditional role has come to shape the historic public image of nurses as care providers. However, nurses are permitted by most jurisdictions to practice independently in a variety of settings depending on training level. Nursing education has undergone a process of diversification towards advanced and specialized courses and many of the traditional regulations and provider roles are shifting to advanced practice levels.
‘Nursing is a profession in which the element of service to humanity is very strong and is characterized by distinctive traditions, skills, knowledge, values and qualities of a discipline. Articulating this value to the community is one of the challenges nursing faces as it evolves responding to very different practice environments’.
Nursing is well known by its practice ingrained with value of ‘caring’ and this intrinsic nursing value is a part of the development of the discipline of nursing and it now evolves to meet the emerging needs of the community. Nurses and midwives are frontline providers in delivery of cost-effective and quality health care and their contributions to health care development and towards achieving the Millennium Development Goals (MDGs) are extremely crucial.
Nursing services and educational facilities in India have expanded considerably since independence. Nurses are accessible even where doctors are not available and provide health care at the doorstep. Nursing roles and responsibilities have multiplied over the years, but there are huge concerns with regard to the development of the pre-service and in-service training and human resources (HR) issues for their career growth.
It has been observed that there is a workforce crisis due to unemployment and underemployment in nursing across the country irrespective of having immense human resource potential in nursing. The retarded development of nursing and nursing profession seems to be mainly due to the fact that no serious thought has been given to this discipline over the years. Timely action on the various reports submitted to the government would have prepared nurses to take care of all areas of health care delivery and would have also avoided multiplication of other categories like physician assistants, respiratory therapists, technicians, health educators, etc. All these are doing nursing duties.
Nursing Education in India
Nursing education prepares nurses to practice in a variety of settings. Ancient days’ nurses were trained using an apprenticeship model. Long hours at the bedside were supplemented by some pearls of wisdom dispensed by physicians. By the middle of the twentieth century, it became clear that effective nursing practice required a distinctive body of knowledge. Nursing interventions had gradually become independent of the physician's orders, and nursing required integrated knowledge of the physiological, psychological, and social dimensions of the patient. By developing programs of research, nurses asserted ownership over the knowledge required for practice.
On 15th August 1947, India became independent and social changes were taking place rapidly but an alarming absence of public health and sanitary measures continued. The ratio of nurse to patient remained dangerously low. The opening of nursing schools associated with college gave nursing profession a higher social and economic status, than it had previously known. The formation of many commission and committees, establishment of INC brought about change in nursing education.
Growth of Nursing in India
- ANM institutions increased from 307 to 1,642 with admission capacity enhanced from 6,860 to 46,719
- GNM institutions increased from 753 to 2,670 with admission capacity enhanced from 29,008 to 109,224
- BSc(N) institutions increased from 266 to 1,578 with admission capacity enhanced from 11,953 to 80,245
- PBBSc(N) institutions increased from 38 to 617 with admission capacity enhanced from 893 to 20,378
- MSc(N) institutions increased from 38 to 535 with admission capacity enhanced from 483 to 10,026.
History of evolution of nursing education in India
1871—School of nursing started in general hospital Madras.
1886—School of nursing in a full-fledged form was started in JJ Hospital, Bombay.
1892—Many hospitals in Bombay started nursing associations which were intended to provide additional facilities for the training of local nurses.
1908—Trained Nurses Association of India (TNAI) established.
1910—United board of examination for nurses was organized.
1913—South India Board was organized.
1926—First nurses’ registration act passed in Madras.
1935—Madras and Bombay nursing councils were established.
1942—ANM program started.
1943—School of Nursing at RAK College, New Delhi.
1943—Diploma program in nursing administration started in New Delhi.
1946—Four year BSc nursing program started in RAK College and CMC, Vellore.
1947—INC act was passed.
1949—INC was established.
1959—MSc Nursing started in RAK College of Nursing.
1963—Postbasic BSc program started in various institutions.
1968—MSc Nursing at CMC, Vellore.
1972—Basic degree program started in Kerala.
1985—MSc nursing started in CMC Ludhiana.
1986—Curriculum change for GNM program from three and a half years to three years.
1986—M Phil. program started in RAK, Delhi.
1987—MSc Nursing started in Kerala.
1987—Separate directorate of nursing was created in Karnataka State.
1988—MSc Nursing at NIMHANS.
1992—PhD in RAK College, New Delhi.
1992—Postbasic program started under IGNOU
1994—MSc nursing at Mahe, Manipal
1994—Basic BSc program under school of medical education in Mahatma Gandhi University, Kottayam.
1996—MPhil and PhD at Mahe, Manipal.
2001—PhD at NIMHANS.
2004—Syllabus of all nursing courses revised and implemented from 2006 onwards.
2008—Post basic diploma in 10 nursing specialties including independent nurse practitioner in midwifery was developed.
2004–2012—Growth of Nursing Educational Institutions with 5 to 16% in government sector and 84 to 94% of admission capacity produced by private schools and colleges of nursing emerged.
Review of Organization in India
Indian Nursing Council
The Indian Nursing Council is a national regulatory body for nurses and nurse education in India. It is an autonomous body under the Government of India, Ministry of Health and Family Welfare, constituted by the Central Government under section 3(1) of the Indian Nursing Council Act, 1947 of Indian parliament.
- To establish and monitor a uniform standard of nursing education for nurses midwife, auxiliary nurse-midwives and health visitors by doing inspection of the institutions.
- To establish and monitor a uniform standard of nursing education for nurses midwife, auxiliary nurse-midwives and health visitors by doing inspection of the institutions.
- To recognize the qualifications under section 10(2)(4) of the Indian Nursing Council Act, 1947 for the purpose of registration and employment in India and abroad.
- To give approval for registration of Indian and Foreign Nurses possessing foreign qualification under section 11(2)(a) of the Indian Nursing Council Act, 1947.
- To prescribe minimum standards of education and training in various nursing programs and prescribe the syllabus and regulations for nursing programs.
- Power to withdraw the recognition of qualification under section 14 of the Act in case the institution fails to maintain its standards under Section 14 (1)(b) that an institution recognized by a State Council for the training of nurses, midwives, auxiliary nurse midwives or health visitors does not satisfy the requirements of the Council.
- To advise the State Nursing Councils, Examining Boards, State Governments and Central Government in various important items regarding nursing education in the country.
- To regulate the training policies and programs in the field of nursing.
- To recognize Institutions/Organization/Universities imparting Master's Degree/Bachelor's degree/PG Diploma/Diploma/Certificate Courses in the field of nursing.
- To recognize Degree/Diploma/Certificate awarded by Foreign Universities/Institutions on reciprocal basis.
- To promote research in nursing.
- To maintain Indian Nurses Register for registration of Nursing Personnel.
- Prescribe code of ethics and professional conduct.
- To improve the quality of nursing education.