Foreword:

The role of nursing placed in the current scenario has evolved over time, as it reported by Tanya Buchana, (1999) based on a true story. One fine day, there were hundreds of nurses gathering in a campaign holding posters and placard which had phrases written in it asking for raise in pay without added conditions. One speaker from the group in order to get a verbal response started reading the placard one by one. The nurses were excited and started cheering the speaker, who was not a nurse himself, after each placard was read. When he read the final placard, he questioned the nurses, “Is Florence Nightingale dead?” His idea was to kindle and create a spark among the group asking this stirring  final question The entire campaign of nurses went silent for a while, after which they started whispering among themselves in frenzy.

All the nurses were taken aback and silence prevailed for a very long time. After a few minutes, few of the nurses started laughing uneasily, and some even found the question offending. Some nurses from the crowd started asking the same question among them; “Is Florence Nightingale dead?”. But none of them from the crowd were able to reply back clearly. This showed the lack of certainty among the nurses when it came to the position of Florence Nightingale in the role of nursing. One possibility is that, none of them has thought about the role Nightingale has played in nursing or questioned themselves on the subjects. Further, there was not much distinction between the person Florence Nightingale was and the function her name has come to, in terms of her role of nursing.

Here, I would like to explain how nursing, an important the role in wars and military has evolved over time and the historiography of it linked to Florence Nightingale. There is a difference between history and historiography, because, history, simply means what has happened in the past, but on the other hand, historiography is what has been written about what happened in the past. History is a very vast term and it typically depicts what happened every day and most of it is not recorded.

According to the great historians Michael de Certeau, Hayden White and Michael Faucault, history is nothing but a recording or writing of what happened in the past. According to them, history, which is written, is greatly influenced by the political conditions as well as the power relations of the situation when it is written (Reznick,2011).

This paper does not praise or censure Florence Nightingale or her contribution to the field of nursing. This is just a mere attempt to represent the reader with an efficient history with no criticisms or credibility. As a matter of fact, it is not possible to ignore the existence of a Florence Nightingale, when we describe about the history of nursing. When we talk about nursing, it has been greatly influenced by her personality and her role. However, discourse will not be able to reproduce what Florence Nightingale had done in reality, as against what is produced arc virtual Florence Nightingale (cl. de Certeau 1988:8). The account in this is written by a nurse to be read by nurses to help them enhance the role and responsibility.

War nurse 5

Background

The accounts of history of nursing written in both 19th and early 20th centuries have undergone a lot of criticism and were published somewhere in the 1980s. This resulted in the production of the revisionist accounts (Davies, 2007). Most of the reports that were published or recorded prior to 1960 were just used to rationalise the process of professionalization (Rafferty, 2000). As per the historians, this was the right approach and it was used to bring in more new entrants into this profession, and also to differentiate trained nurses, women who have been doing this without much training as they had claimed the title before the nursing reforms were introduced in the mid 19th century , (Nelson, 2002 ).

History was generally recorded and written in a congratulatory style. This was to provide a simple, precise and uncomplicated version of the history to the readers. It did not address the economic reality or complexity of the situation, social and other important conditions that influenced nursing. Further, it did not even account the role of gender or class or religion played (Mortimer, 2005; Sweet, 2007). This is not a single case that has to be ruled out while writing about the history of nursing. One can see that on the accounts of history of nursing in wars, it features a number of historical events and accounts, and it is even recorded in histories of hospitals written by nurses (Newby, 1985) and doctors (Granshaw, 1989). One can find that, the importance given to the mainstream society when describing how nursing operated or developed in minimal to nil(Margaret  et al 2002).

In this paper, we will discuss the important issues that had great amount of influence on evolution of nursing. Further, we can also discuss how the nursing management developed from its roots in the 19th century to the present stage. This will help us understand the organisation of nursing as a whole in a contemporary way.

When we take into account the development of management of nursing in the United Kingdom, there are 2 different periods that seem to have been mentioned over and over again in the literature. The 1st one is between the middle and the end of the 19th century and the 2nd one is between after the creation of National Health Service in 1940s and the introduction of General Management in 1980s ( Moiden, 2002).

war nurse 4

Role of Nursing during the Wartime

The role played by the American nurses during the wartime for the American military is undeniably one of the most important aspects. The nurse’s duty was very simple in military; which is to provide care and aid to all the soldiers who had wounded themselves in the war. Further, it was also their responsibility to take care of the casualties of the war. If we go through the history we will understand that the view of a military nurse has changed to a greater extent from that of a simple recyclable source used only during the military necessity to be called upon only during the time of crisis to part of the team.

Florence Nightingale, with a team of 38 nurses sailed a ship to Turkey to be an unwelcomed guest and provided with an appalled situation and very poor sanitary facility. Further, both the military doctors and the health officers had refused to take into account Florence’s attempts to revamp the military hospital. Only later, when Florence succeeded in the Crimean War, high standards for a nurse and the practice of nursing was established. Post which the number of nursing schools increased and the growth and development of the schools also improved the qualification of nurses and they came to be officially recognised, even in the military hospitals (Buchana, 1999).

war nurse 2

The American Civil War and Nursing

It was only during the American Civil War that women were offered responsibility and introduced as female staff, in the traditional male dominated military environment. This also had a significant improvement of women’s liberalisation in the later days in American society (“Civil War Nurses: The Angels of the Battlefield,” N.D.). The two most important women in revolutionising the nursing concepts were Dorothea Dix and Clara Barton. They were very powerful and changed the concept of nursing during the Civil War. Both of them worked independently in organising a nursing corps, which concentrated on taking care of the sick and wounded from the war. They were also given the title of Superintendent of Women Nurses. Dorothea Dix also known as the ‘Dragon Dix’ was worthy of the title. She also changed the concept and hired middle-aged women who had plain looks to serve as important nurses in Army Medical Bureau. She was proud of her nickname as she successfully created the country’s 1st professional nursing corps Army. Post-Civil War, Clara Barton headed the creation of American branch of the International Red Cross. She was a schoolteacher who shifted base from Massachusetts to Washington to provide nursing care for the injured soldiers of war. By the time, the Healthcare had improved nationwide better and this helped the nurses aid the injured and sick from the war disasters. Further, as they had developed experience, they were also well prepared to manage the future wars or similar conditions, according for a crisis situation ( Blum,2011)

The sign of health care

The World War- I

In 1917, when the United States joined the World War, the number of nurses was very low. However, over a period of time, the number of nurses recruited for active duty increased and it did not in decrease for over a year. When the war ended in November 1918, there are over 21,000 active nurses as part of the ANC and around thousand 400 nurses as a part of the NNC (Reznick ,2011; Cox, 2001).

As the number of casualties during the World War- I was very high, the number of nurses who were well trained and skilled was wanted in great demand. The American Red Cross served as a wing that supplied the well trained and skilled nurses to both the Army and Navy to serve as a part of the wartime nurse corps (“Health and Medicine: Red Cross and World War I,” n.d.). The duty of ANC was to serve in the evacuation zones, mobile travelling units or the surgical units which cared for the wounded. Further, the nurses who work in the hospital train and transport ships during the war throughout the European continent, attending to the soldiers were wounded and sick and those crossing the Atlantic Ocean back to the country (Cox, 2001). This was when the nursing profession had reached its new height. Further, it was the idea of the Navy to create base hospitals in Ireland, Scotland and France. Later they sent in small groups of nurses and mobile units to stay close to the battlefronts. Despite the fact that the nurses were able to provide onsite care for the wounded soldiers, their contribution to serving those returned soldiers back home was undeniably excellent and considered as an accomplishment by the nurse corps. Most of the nurse is in the team served in this providing the basic care to the soldiers and also training the new nurses in the corps. As this was the pre-antibiotic era, the nurses gave priority to clean and hygienic environments, the better chances of saving the wounded (“Nurses and the U.S. Navy, 1917-1919,” 2005).

After a few years, the number of active nurses decreased gradually as the need for them decrease as well. However, though military did not need the number of nurses, the government realised that no war can be won without the help of health care providers. So, this was one of the breaking point that gave the nursing profession a good recognition and was acknowledged for what it was worth.

war nurse 1

World War- II

For the Americans, the world was started on December 17, 1941, after the Pearl Harbor was bombarded by the Japanese army. Post which NNC and ANC recruited 69,000 nurses to take care of the wounded and sick soldiers.They were divided into groups and they worked in the field onsite, medical transport planes, evacuation, hospitals, hospital ships and hospital trains. The medical transport planes were launched as a new part and were called Flight Nursing (Commager, 2002).

When the war began, they were awarded the ‘relative ranking’ and recognised as officers and even provided uniforms. But, they were not eligible for commissions or privileges that were given to the men who served in the Army. Later in the year 1944 22nd June, the Congress government granted the nurses the same privileges and temporary officers rank to all the ANC and NNC nurses who deserved. They were also given the same benefits and commissions, rights and pay at par with the officer of the same cadre. The compassion and the hard work of the nurses had also received the acknowledgement and praises from the society (Blum,2011;Kalisch&Kalisch, 2004).

As the nurses were well-trained and able to provide proper nursing care to all the wounded in the World War II, almost 96 soldiers out of hundred who were wounded were saved. This means, only about a 4% of the injured and diseased soldiers died. After end of the war, the society looked upon the field of nursing and as a dignified profession and acknowledged the women who served as nurses in the war. The government announced free nursing education to be provided to all interested in deserving candidates till 1948. As the nurses from the military services had skills developed through experience, they were able to handle wounds and deaths better (Bellafaire, 1993).

War Nurse 3

The War of Vietnam

The Vietnam War which happened between 1959 and 1975 proved to be a very difficult time for the Americans. The need for nurses increased rapidly and the military started recruiting throughout the period. According to an account from, there was already a shortage of nurses in the society. Most of them were reluctant to go and serve in the army as they had opportunities to serve the civilians. The government announced financial aid to all the nurses who served in the Army during the Vietnam War. Recruitment of nurses in the military proved to be even difficult because, the civilian hospitals in the country offered better pay packages and also better working conditions (Teerawichitchainan, 2012; Kalisch&Kalisch, 2004)

 

Iran-Iraq War -1980-88

The Iranian nurses performed most important roles during Iran-Iraq war during 1980-88. The nature of nursing practice in chemical emergency departments was very crucial during this war. The clinical tasks were allocated to the specific nurses in a situation in which they become exposed to chemically contaminated patients and direct attacks on emergency department. Most of the nurses become affected from a gas “Mustard Gas” and suffered from eye, skin and respiratory system diseases. Many of them are still suffering from ill effects of that chemical.(Firouzkouhi et al 2013)

Vietnamtunnel

Gulf and Afghanistan war:

Around 1980s feminist movement has gained advancement in the country and hence women became more and more liberal. Most of them in when given an option to choose being just a mother/ housewife chose to be a business owner as well as a mother. During this time, the military nurses had to be deployed to Afghanistan in 1990s. It further complicated the family situation as Gulf War was the 1st incident in which mothers left their children behind to work in a different country (Schoenfeld, 2012).

During this period, 2200 nurses were recruited and appointed by the military moved to the Middle East under ‘Operation Desert Shield’ . As they had received ample training and prepared for the worst case scenario and distress situations they were able to handle the casualties better. This was the 1st war in American history in which the deployable medical systems were used and combat support hospitals were established. These combat support Hospital were called DEPMEDS and they were constructed using rigid aluminum tents. They were well equipped with pharmacy, radiology, laboratory, surgery departments and sterilisation departments. This was the 1st time when the infliction of diseases faced by the nurses was reduced to a greater extent due to high level of hygiene (Schoenfeld, (2012).

In this period of time, the US military was able to develop excellent combat surgical assets. In this, any injured member can be immediately drawn from the battlefield to the medical facility and at the same time treated during the transportation.

During Iran and Afghanistan wars in 1990s, the Critical Care Air Transport(CCAT) team were used to a larger extend. The critical care team had well-trained physician, respiratory therapist and a critical care nurse. These units are generally called to transfer those who have been wounded severely in the war and to stabilise physical condition of wounded soldiers. The team provides medical care, en route to the hospital, be it out of the war zone or back home to United States. The care given to the wounded patient might vary right from basic first aid care do even life support interventions. This depends upon the availability of the surgeons or the specialised physician (Schoenfeld, 2012).

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The Americans War on Terror

When the incidence of September 11 took place, the policies in establishing the Forward Surgical Teams (FST) and Combat Support Hospitals (CSHs) were in the infancy stage. Only during this incident, and after the establishment of global war on terror, the combat surgical units were used. As the military is aware of the nature of the war and the capability of the enemy, FST or CSHs has never been deployed for the intended purpose. However, it has been functioning as medical treatment centers, and combat support centers during a crisis situation. However, they have not come to a conclusion as to which model best suits the asymmetrical battlefield.  Responsibility was handed over to a team of experts to determine which would serve the purpose better. The mortality rates of people who went for initial treatment to an FST unit were compared to a member receiving all the treatments from CSH. Regardless of the differences, capabilities, as well as the supplies, they were not able to find any reportable statistical difference in terms of survival between the CSHs and FSTs (Garfield et al, 2003).

Nursing management & education in the 19th century

A defining feature of much of the literature about this period is its concentration on the actions and influence of Florence Nightingale. She indeed performed a leading role in nursing reformations and introduced the word “ matrons” in the  hospitals, as part of a new regime which constituted a clean break with the past (Girvin, 1996;Moiden, 2002). The skills introduced by Nightingale were marvelous and her supporters advocated her views, and emphasised  application in the success of the Nightingale School of Nursing (Margaret  et al 2002).

In 1854, she was appointed head of nursing school and she assumed the responsibilities when it was established in 1860. She held this office for 33 years, until some feminists started raising objection on failure and abilities along with Bonham-Carter who was secretary of the Nightingale Fund. However, Nightingale contributed a pioneer role in the reform of nursing to Wardroper in 1896 and depicted herself as a powerful force in its development.This positive presentation of Wardroper’s contribution, in contrast to Nightingale’s views of her qualities when she was alive, can be read as a selective reporting of events at a later point in order to enhance the celebratory (Baly, 1997).

In the19th century, attentions were focused on development and improvement of hospital nursing for the sick poor, both in the voluntary and poor public hospitals. These developments have attracted extensive attention from historians and consequently, the history of nursing become associated with the history of nursing in the voluntary general hospital in later decades of 20th century (Carpenter, 1980; Rosenberg, 1982).  Consequently, the management of nursing is discussed as a whole for volunteer hospitals and development of systems in general nursing (Margaret et al 2002).

In the voluntary hospitals, the medical staff acquired extra powers by their involvement in all decision making committees. Margaret et al (2002), emphasized on the role matron for nursing managements and other in house affairs of the hospitals. However, the role and function of the matron were affected by the constitution of rules developed by the National Health Service in 1948 which resulted into grouping of hospitals together for administrative purposes. The matron was forced to work in partnership with the senior administrations of the medical staff to manage the individual hospitals. In England and Wales the Matron was supposed to be present in committee meetings for involving nurses in any discussion regarding them which may be raised by the Governing Body. In this way the matron of the individual hospital became relegated in terms of decision and policy making at the highest level in the new local health service structure (Redman, 2008, Wildman and Hewison, 2009)

  1. Education and management in Australia

As per Margaret et al, (2010), the new nurses found difficulty in Australia while discussing the history of nursing. While most of the students valued teaching history of nursing, they found that the curriculum was over emphasising on technical skills and requirements. At the same time the new nurses were expected to be able to meet unrealistic work pressure. Further, they were also expected to be ready with little to no training at all. According to them, the history was only able to help them to develop the critical thinking and improve professional identity as a nursing student. Including nursing history in the curriculum will help the prospective nurses to prepare themselves to maintain professional ethics and also motivate them and reinforce their identity.

  1. Education and management in Egypt and China

Similarly, in countries like Egypt, the nursing education system developed based on the influence of social, political and economic structure of the current scenario. We can only conclude that most of the developing countries when compared to each other showed that the development of this is totally dependent upon the efforts put in to improve the educational background of the nurses. However, the countries that gave importance and improved their educational preparation based on the requirements of the population showed better nursing education system. Neither could Egypt nor China were able to increase the entrance requirements (Chenjuan et al 2012).

  1. Education and management in Iraq

The war inflicted country of Iraq has significantly suffered due to the wars and this in turn has taken a huge toll on the health system of the country. As the situation has been the same for over 20 years, there is tremendous stress on the health system. The health professionals are not well equipped or skilled as they need to improve their understanding on the current problems. First and foremost, they should take steps to review and improve the health care system and start supporting and accepting their nursing staff. Over the last 5 years, many organisations which include NGOs and union nation delegates have stressed the importance of health-care system and the improvement of the country has to make in it. The government should take measures to review and then take measures to strategise the development of health system, resolve current issues and also improve the quality of nursing (Garfield et al, 2003)

As  discussed, due attention was given for improvement of nursing practices, management, and education after Crimean War, consequently fatality rate dropped in subsequent wars.  The percentage of fatality rate in word war 11, Vietnam, Iraq (Operation desert storm),Gulf and Afghanistan war is presented graphically in figure-1(Schoenfeld, 2012).

                                                    

Nursing Informatics

Nursing informatics is a technique which is developed to use nurse’s information by computer technology .Nursing informatics enhances nursing knowledge and practice by providing better management.

Baker (2012) studied nursing informatics and elaborates different effects on nurses. He considered system and science to coordinate arrangement of working elements for development of precise measurement of knowledge. He divided the research into cognitive, information, computer and nursing science and presented the data analysed in graphical form to evaluate overall nursing informatics. The graphical representation is shown in the figure by redrawing t data.

Saba (1997) provided overview of medical Informatics to focus the new nursing specialties. The researcher provided an overview of data standards, goals, and scope and research initiatives to design the advanced status of nursing informatics

 

                       

 Fig-2:  Nursing Informatics

Background on the Crisis

Regardless of the need for war on Iraq, the nurses should be able to understand the health consequences that the Iraqi civilian population is facing. What kind of health facility should do the Iraqi health professional and provided to the civilians? First-hand accounts should be provided which includes historical context, cultural and unbiased observations. After the Iranian war ended in 1989, the number of nurses in the country had increased to about 12,687, out of which about 6000 of them were qualified. After the 1990, almost 20 universities offered bachelorette coldness in nursing. By the end of the year 2000, the number of nurses in the country increased to about 56,800 out of which about 50% of them hold bachelorette degree as per the country’s financial ministry. However, this information should be analysed as the available data between 1978 and 1997 shows a lower figure of prospective graduating trained nurses. As there are constraints on women in the country, both culturally and socially, the war has worsened the situation further and also reduced the economy. This is not a case of just the nursing but overall in a wider context (Hodgson, 2007; Garfield,2003).

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The Famous Personalities in the History of Wars

A survey conducted by Margaret et al, 2010, on the Australian nurses and the role played by them showed the contributions made by a number of historical personalities, specifically those who served during the war period. The 1st name that is mentioned is Florence Nightingale, who is considered to be the lady who changed the outlook of nursing. Few other names are Mary Seacole, Edith Cavell, Mother Teresa and Dorothy Dix; they are internationally famous nurses. The 2 personalities who changed the face of nursing during the civil war in America; Clara Barton and Dorothea Dix get a special mention in our review (“Civil War Nurses: The Angels of the Battlefield,” N.D.). Another famous personality who came to be famous during the Vietnam War is Diana Carlson Evans. The Russian nurse Alexander Kerensky was the one who changed the face of nursing in Russia (Alexandra Feodorovna: Alix of Hesse”n.d). Likewise, 2 other famous personalities in the field of nursing are Cheryl Ruff ( Rushton et al, 2008) , who made tremendous contributions to nursing in the operation ‘Desert Storm’ that took place during the Iran War and Ana Justina Ferreira Neri who contributed from Brazil during the Paraguayan War (“Paraguayan War” n.d.)

However, it would be a difficult task to remember and mention the names of all the nurses who had served their duties and saved the lives of millions of soldiers and civilians during the wartime. The history behind their life can only be brought to limelight through biographical accounts, which in turn will inspire the aspiring nurses to contribute. Further, it will also help them be prepared, gain confidence, be resilient and at the same time overcome the challenges. However, one should understand that all achievements and struggles were not achieved by single personalities or in isolation.

Conclusion:

An average American in the real sense witnessed the war or ‘saw’ the war and the effect it had on people via clips and pictures that were telecasted in the TV and published in newspapers. The Vietnam War showed the face of violence to the civilians who had no idea how wrathful a war would be in reality. When the soldiers returned back home from Vietnam they received a very low support by the civilians. However, this was the war in which the nurses who served in the military and helped millions of soldiers receive acknowledgement and praise. Vietnam Women’s Memorial shows the respect and support for all the military nurses who had worked in the war. One can say that though war brought about death, pain and tragedy, it also helped in improving the medical and nursing care. Further, this was also the time when the military personnel and the government understood the importance of nurses, as well as the effect of proper medical and emotional care to the wounded soldiers. After the Crimean war ended, the nursing profession gained new heights. To Support the war on terrorism by the Americans; over 2000 military nurses who are well trained and equipped, have been deployed to Iraq. One can never know what the positive or negative effects a war will have on any country, but nursing profession will definitely serve its purpose, just like it served in all its wars and crisis situations.

 

 

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