The History of Nursing Education in the U.S.

 

The introduction of formal education for nurses began in the U.S. in the late 19th century. White women reformers introduced nurse training programs in hospital-based nursing schools to help modernize the hospital and provide suitable employment for growing numbers of young women seeking paid work. In the apprenticeship-like training system, students provided the majority of patient care activities in the hospital in exchange for instruction in nursing. Training programs were generally two to three years in length; students learned at the bedside while caring for patients, they also attended lectures taught by physicians. After completing the program, students earned a diploma and were eligible to work as a trained nurse. The first nurse training schools, which opened in 1873, were New York Training School at Bellevue Hospital, Connecticut Training School at State Hospital in New Haven, and Boston Training School at Massachusetts General Hospital. By 1900, there were between 400 and 800 nursing schools. Most hospitals established nurse training schools to develop their own student nursing workforce. As such, admissions standards were tied to the hospital’s labor needs. Through the first half of the 20th century, nursing leaders’ efforts to improve and standardize nursing education were undermined by hospitals’ reliance on nursing students as cheap and malleable labor.

The white women who pushed for nursing reform were influenced by the reform efforts of Florence Nightingale in England. According to Nightingale, training would not only provide students with necessary technical skills, but would also instill proper character, characterized by discipline, ethical behavior, and loyalty and deference to nursing superiors and to physician authority. Under the Nightingale schema, the ideal nurse was to be white, middle class, and female. Ideologies of race, gender, and class, thus, intersected in the development of nursing education and shaped the experiences and identities of those who trained as nurses, including nurses of color and men nurses who navigated race- and gender-based barriers to nursing education. In the North, white nurse leaders imposed strict racial quotas on nursing school admissions. In the segregated South, Black women could only train at schools established at segregated Black hospitals. In 1886, the first Black nurse training program began at Spelman Seminary in Atlanta, Georgia. In 1891, Virgina’s first Black nurse training school opened in Hampton, Virginia, at Dixie Hospital. These early Black hospitals and nurse training schools were established by white philanthropists and municipal governments and overseen by white physicians and white nurses; Black physicians and nurses were typically restricted from holding supervisory or leadership positions. During the early 20th century, in the context of segregated and inequitable health care, Black physicians, educational institutions, churches, and community organizations established hospitals controlled by and for Black Americans. The founders of Black hospitals established them to provide much-needed services to the Black community and to serve as sites for the training and professional development of Black nurses. By 1920, there were 40 separately Black nursing schools compared to 1,715 predominantly or exclusively white nursing schools.

Men also faced discrimination in their efforts to purse nursing education. Until the 1960s, most nursing schools prohibited men from enrolling, although some schools attached to psychiatric hospitals and tuberculosis sanitoria were open to men. The first nursing school for men, Mills Training School for Men, opened in 1888 at Bellevue Hospital in New York City. Even after graduating and earning a diploma, men nurses were often relegated to the gendered category of “orderly” – an untrained position. During the 1910s, the first general training schools for men opened, in part in response to demand for more nurses stimulated by hospital expansion and World War I. The overwhelming majority of men who graduated from general nurse training programs through the 1960s were white and working-class or middle-class.

The first university-based schools of nursing were established in the early 20th century and offered post-graduate education to registered nurses interested in becoming administrators, educators, or public health nurses. The earliest baccalaureate programs in nursing, first introduced in 1909, prepared RNs for such careers. In a few programs, students could earn a baccalaureate degree after completing two years of liberal arts study alongside three years of hospital-based training. By the mid-20th century, university-based nursing schools were increasingly the site of both general and post-graduate nursing education. After World War II, in the context of the increasing complexity of patient care and growing demands for hospital services, nursing leaders began calling for the closure of hospital-based diploma programs and locating all forms of nursing education at universities and colleges. Recognizing the limits of the regimented, procedure-oriented hands-on training of the hospital-based training programs, nurse leaders introduced new models of university-based nursing education. The new baccalaureate of science in nursing (BSN) programs integrated the liberal arts, sciences, and nursing theory. The new BSN programs emphasized the nursing model of care and prepared professional nurses for their work as independent and expert clinicians.

Nurse educators also introduced new programs to tackle persistent nursing shortages after World War II. The demographic impacts of the baby boom generation, the health care needs of the aging population, the growth of employment-based health insurance, and the introduction of Medicare and Medicaid in 1965, all contributed to the expanding demand for health care services and, thus, nurses. In the early 1950s, nurse educators introduced a new type of collegiate-based nursing education – the associate degree in nursing (ADN) offered at community colleges – which was intended to prepare nurses who would perform more of the traditional bed and body work of nursing. In the early 1950s, there were seven associate degree programs and by the mid-1970s, that number had increased to almost 700. Nurse educators also expanded the number one-year programs to train licensed practical nurses, (LPN), typically in hospital-based nursing schools or vocational educational systems, that prepared graduates to perform the putatively lower-skilled nursing work delegated by registered nurses. Between 1950 and 1963, the number of LPN programs grew from 144 to 737. Both the introduction of the ADN and the expansion of LPN programs were an effort to educate greater numbers of nurses in shorter time for lower skilled nursing than that would be performed by diploma-trained and BSN-educated nurses. Graduates of associate degree, diploma, and BSN programs, however, all sat for the same licensing exam to earn the title of registered nurse (RN).

Because of ongoing racial discrimination in higher education and nursing, the educational reforms of the 1950s and 1960s reinforced and exacerbated existing racialized hierarchies in nursing. Even after civil rights legislation in the 1960s dismantled the legal system of segregation and made racial discrimination in education and employment illegal, practices of racial exclusion in nursing and higher education continued. By the 1970s, Black women were overrepresented among LPNs but underrepresented among BSN-educated nurses. At that time, the majority of RNs of color graduated from ADN programs, which limited their opportunities for career advancement, leadership, and faculty positions, all of which required, at minimum, a BSN.

By the 1960s, increasingly complex, specialized patient care had created new roles for nurses who had undergone advanced clinical training – at the master’s degree level – in various nursing specialties. The nurse practitioner movement of the 1960s and 1970s, which in part was intended to solve the growing shortages of primary care physicians, also expanded the demand for clinical master’s programs. Beginning in 1960s and 1970s, nursing schools also began introducing second-degree programs, which expanded in the 1980s onwards, again, with a view to addressing the nursing shortage.

New doctoral degree programs in nursing were introduced in the 1960s and 1970s, which prepared nurses for roles as researchers and faculty. In 1924, the first doctoral program in nursing was established at Columbia University, which conferred a doctorate in education. The first program to offer a PhD was launched in 1934 at New York University. These early doctoral programs were focused on preparing expert nurse educators rather than nurse researchers. When nurses did research, they focused on educational and occupational studies. The movement to establish nursing science as an academic discipline, and to launch PhD in Nursing programs to prepare nurses to conduct clinical nursing research and advance nursing science emerged in the 1960s. The movement was prompted by the changing health needs of individuals and populations, significant changes in the clinical environment, and the need for nursing faculty to define and secure their permanent place in the university. As nurse scientists competed for research funding and professional status within the broader health care research community, they transformed nursing practice – particularly, the nurse-patient relationship – into a site of valuable research and knowledge production and demonstrated the ways in which application of this knowledge is integral to improving patient outcomes and healthcare delivery. By 2021, there were 150 research-focused doctoral programs in the United States.

From the beginning, nurse scientists considered how to most effectively translate the knowledge developed from research into clinical practice and to ensure advances in nursing science translated into improvements in patient care and health outcomes. By the late 1970s, nurse educators debated the value of a practice-focused doctorate. The practice-related doctorate, which took the form of the (eventually failed) doctor of nursing (ND) degree, and then later, the doctor of nursing practice (DNP) degree, would place nurses on an equal professional footing as their colleagues in medicine and dentistry, while also preparing expert nurses responsible for translating research knowledge into meaningful practice and policy. By the turn of the 21st century, nursing leaders had reimagined the DNP as apex of excellence as practitioners, including as scholars of the practice environment. In its 2004 position statement, the American Association of Colleges of Nursing recommend that the DNP become the graduate degree for advanced nursing practice, including the roles of clinical nurse specialist, nurse anesthetist, nurse midwife, and nurse practitioner. Between 2007 and 2023 the number of DNP programs jumped from 53 to over 400 with another 90 in the works.