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Letter to the Editor

Historical Perspectives on an Expanded Role for Nursing

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Arlene W. Keeling, PhD, RN, FAAN

Abstract

The 2010 Institute of Medicine report, the Future of Nursing, recommended that nurses work to the “full extent of their training” to address the primary healthcare needs of United States citizens. This article identifies and describes historical antecedents, cornerstone documents, and legislative acts that served to set the stage for today, laying the groundwork for an expanded role for advanced practice nurses in the 21st century. Beginning with Lillian Wald’s work in Henry Street Settlement in 1893, through Mary Breckenridge’s founding of the Frontier Nursing Service in 1925, the discussion describes how nurses provided access to care for thousands of urban and rural citizens throughout the United States in the past. The article also discusses political forces at midcentury and the creation of the nurse practitioner role with the premise that nurses can learn from these early initiatives to create new models for nurses’ roles in primary care today.

Citation: Keeling, A., (May 31, 2015) "Historical Perspectives on an Expanded Role for Nursing" OJIN: The Online Journal of Issues in Nursing Vol. 20, No. 2, Manuscript 2.

DOI: 10.3912/OJIN.Vol20No02Man02

Key words: history, expanded nurses’ roles, IOM Report 2010, access to care, ANA definition of nursing, Committee to Study Extended Roles, Lillian Wald, Mary Breckenridge, Food and Drug Act 1906, Frank v. South, Harrison Narcotic Act

Combining primary care medical services with advanced practice nursing skills, NPs meet the needs of underserved rural communities or those who lack access to care in inner cities. From the inception of the nurse practitioner (NP) role in the 1960s, NPs have been identified as healthcare providers who can serve a combination of needs. Combining primary care medical services with advanced practice nursing skills, NPs meet the needs of underserved rural communities or those who lack access to care in inner cities. However, the nurse’s role in providing access to care for underserved populations throughout the United States predates the inception of the formal nurse practitioner role by almost three-quarters of a century. This article identifies and describes several historical antecedents, cornerstone documents, and legislative acts that served to set the stage for today, laying the groundwork for an expanded role for advanced practice nursing in the 21st century. Beginning with Lillian Wald’s work in Henry Street Settlement in 1893, through Mary Breckenridge’s founding of the Frontier Nursing Service in 1925, the next section describes how nurses provided access to care for thousands of urban and rural citizens throughout the United States in the past.

Lillian Wald and the Henry Street Settlement Visiting Nurses

As demand for the nurses’ services increased, so did the numbers of nurses on the HSS staff and the need for regulation of their practice. In 1893, during a period of rapid industrialization and immigration in the Northeast, Lillian Wald, a young graduate nurse from New York Training School, established the Henry Street Settlement (HSS) on the Lower East Side of Manhattan (Keeling, 2006). Initially she and her colleague, Mary Brewster, made visiting nurses rounds there, providing not only physical care to the poverty-stricken European immigrants but also mobilizing an array of services to provide them with such necessities as ice, sterilized milk, medicines, and meals. In addition, the nurses made referrals to physicians and the city’s hospitals. According to Wald, the immigrants’ needs were limitless: “There were nursing infants, many of them with the summer bowel complaint that sent infant mortality soaring during the hot months; there were children with measles, not quarantined . . . there were children scarred with vermin bites . . . a young girl dying of tuberculosis amid the very conditions that had produced the disease.” (Duffus, 1938, p. 43)

As demand for the nurses’ services increased, so did the numbers of nurses on the HSS staff and the need for regulation of their practice. By 1900, the Settlement employed 12 nurses who made 26,600 home visits. During these visits, nurses routinely dispensed physician-prescribed medicines obtained from local pharmacists and household remedies which they carried in their black leather nursing bags, filled from the HSS medicine closet (Keeling, 2006; Wald, 1901-02, n.p).

At the turn of the 20th century, the medical/nursing professional boundaries changed almost daily as new treatments became available and state and federal legislative acts regulated the professions of medicine, pharmacy and nursing. The nurses’ dispensing practices would be questioned a few years later, however, with the passage of the 1903 state nursing registration act, which declared: “Nothing contained in this act shall be considered as conferring any authority to practice medicine or to undertake the treatment or cure of disease.” (Article XII, 1903). The question was: what constituted the practice of medicine and the treatment of disease in 1903? Did it include the administration of such treatments as mustard plasters and turpentine stupes that were widely prescribed by physicians at the time, but which the HSS nurses routinely gave during their home visits based on their own experience? Did the newly discovered medicine, aspirin, count as a prescription when it was commonly used in upper and middle class households? What about the use of glycerin and honey to treat a sore throat? Sometimes honey and glycerin was prescribed; at other times nurses simply gave it. Another drug at issue was laudanum, a narcotic that was widely used in households throughout the United States.

These issues would come to the forefront with the enactment of the 1906 Food and Drug Act that required the disclosure of such ingredients as alcohol, opium, cocaine, morphine, chloroform, marijuana, laudanum and chloral hydrate on medication labels (Hilts, 2003). At the turn of the 20th century, the medical/nursing professional boundaries changed almost daily as new treatments became available and state and federal legislative acts regulated the professions of medicine, pharmacy and nursing. One solution was Wald’s formation of an oversight medical advisory committee that wrote standing medical orders and provided counsel “on matters dealing with the relationship between the medical and the nursing groups and the development of policies relating to the welfare of patients.” (Executive Committee of the Henry Street Vising Nurse Service, n.d., p. 3)

 

   Prescription for glycerin and honey, circa 1890s. Courtesy of the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry, the University of Virginia.

Clearly, visiting nurses were working at the full extent of their training to provide access to care for thousands of Americans.Over time the HSS Visiting Nurse service grew exponentially. In 1923 alone, the HSS nurses made over 37,000 visits and cared for over 50,000 patients. By 1926 the HSS visiting nurses were making over 300,000 home visits each year, treating such illnesses as pneumonia, polio, measles, influenza, tonsillitis, burns, and tuberculosis (Keeling, 2006). In other cities, like Boston, Chicago, Philadelphia, Seattle, and Richmond, visiting nurses were doing the same. Clearly, visiting nurses were working at the full extent of their training to provide access to care for thousands of Americans.

Mary Breckenridge and the Frontier Nursing Service

In the early 20th century, Leslie County Kentucky, an Appalachian community of 373 square miles with a population of fewer than 11,000, was one of the poorest and most inaccessible areas of the United States. It also had one of the highest maternal and infant mortality rates in the country, very few physicians, and formidable distances and road conditions, making it almost impossible for patients to access medical care in nearby towns. It was in this county that Mary Breckenridge, a certified nurse midwife and member of a distinguished and well-connected Kentucky family, founded the Frontier Nursing Service in 1925, intending to showcase the remarkable differences certified nurse-midwives could make in maternal/infant mortality.

Mary Breckenridge... founded the Frontier Nursing Service in 1925, intending to showcase the remarkable differences certified nurse-midwives could make in maternal/infant mortality. Beginning with the establishment of headquarters at Wendover, a log house overlooking Hurricane Creek, Breckenridge set up a series of eight decentralized clinics, covering 78 square miles of the rugged Appalachian Mountain territory, and providing nursing care for families in three counties (Cockerham & Keeling, 2012; Keeling, 2006). Because there were few roads in the remote region, the FNS nurses traveled by horseback along creek beds and mountain trails to care for the families who needed them. For the most part, the nurses worked alone, without on–site medical supervision. Instead, Mary Breckinridge turned to a medical advisory committee for oversight of the nurses’ practice.

In 1917, the landmark legal decision of Frank v. South helped lay the groundwork for the Frontier Nurses’ practice. In that decision, the Kentucky appellate court ruled that anesthesia provided by nurse anesthetist Margaret Hatfield did not constitute the practice of medicine if the anesthesia was given under the orders and supervision of a licensed physician (Frank v. South, 1917). While the FNS nurses were not nurse anesthetists, they sometimes gave ether during childbirth. Moreover, they practiced in Kentucky and the law set boundaries for the professional practice of nursing. Thus, in order to comply with Kentucky law, Breckenridge set up an advisory committee of physicians who wrote specific instructions for the FNS nurses to follow in cases where a physician was not available. This committee of physicians developed a set of Medical Routines (standing orders) to legally cover the nurses’ practice.

 

 

    Cover of Medical Routines, 1928. Courtesy of the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry, the University of Virginia.

Working according to the guidelines in these Routines, and using the equipment and medicines they carried in their saddlebags, FNS nurses did whatever they had to do to treat common illnesses, deliver infants, and provide emergency care. Typical items in the delivery bag were rubber sheets, aprons, catheters, clamps and scissors—as well as ether and morphine. The general medical bag contained morphine, codeine, quinine, cascara, aspirin, and chloral hydrate among other medicines (Keeling, 2006; Medical Advisory Committee, 1928). Thus, while not technically prescribing medicines, the FNS nurses furnished whatever medicines they had with them, following the guidelines in the manual. In each of the editions of the Medical Routines, the physicians recognized that without the FNS nurses, the inhabitants of Leslie County would not receive care. According to one report:

In most instances, there is no telephone service available, some one must ride the entire distance, varying from 4 to 20 miles, to summon the doctor, who usually lives in some small village or town where he maintains a practice. It is often impossible for him to leave his patients for the length of time necessary to make a trip into the mountains . . . If time and weather conditions permit, they will in an emergency visit those on the outskirts of their own territory . . . In winter, when snow covers the ground and the creek beds are frozen, it is difficult if not impossible for the mountaineer to go for the doctor and equally out of the question for the doctor to come to the patient (Willeford, 1932, p. 15).

Federal drug laws, unclear about the boundaries of the practice of nursing, supported the Frontier nurses’ autonomy and their ability to carry and dispense medications of all sorts, including narcotics. In 1914, the United States Congress had passed the Harrison Narcotic Act, limiting the amount of morphine, heroin, and opium in over the counter remedies and reinforcing the fact that physicians, dentists, and veterinary surgeons could dispense and distribute “the aforesaid drugs only within the practice of their professional duties” (The Harrison Narcotic Act, 1914, p.2., Keeling, 2006, p 56).

In all instances, the nurse was expected to make an accurate assessment of the patient’s condition before choosing to treat with an analgesic. Then she was to use her own judgment to administer an appropriate dose. Nowhere did the act delineate the nurse’s role with regard to narcotics. In fact, the law did not restrict nurses from carrying narcotics in their saddlebags, nor did it prohibit them from administering narcotics according to physicians’ standing orders – orders that were very vague and allowed the nurses to use their own judgment as to the severity of pain and the amount of narcotic to be given. For example, the 1928 edition of Routines stated that morphine sulphate should be given for shock, with doses ranging from "⅛ to ¼ grains, depending on the weight of the patient.” It also recommended that for “acute chest conditions, codeine ¼ to ½ grain doses should be administered for pain or great restlessness." The order followed with recommendations that if codeine was ineffective, the nurse should “give morphine in small doses.” (Medical Routines, 1928, p. 48).

In all instances, the nurse was expected to make an accurate assessment of the patient’s condition before choosing to treat with an analgesic. Then she was to use her own judgment to administer an appropriate dose. Thus, just as the Henry Street Visiting Nurses provided access to care for immigrants in Lower East Side of New York City, the Frontier nurses provided access to medical and nursing care for the residents of this remote rural section of Kentucky (Cockerham & Keeling, 2012; Keeling, 2006). At the close of their ninth fiscal year, the FNS was providing care for 1,146 families, including 256 babies, 1,139 preschool children, 2,243 school-aged children, and 2,337 adults (Willeford, 1935). Clearly the FNS nurses were working to the full extent of their nursing licenses to do so. Without a doubt, part of what they did lay within the domain of public health nursing, such as giving inoculations and doing health teaching. The remainder was a combination of standard home care, primary medical care, and midwifery services.

Political Forces at Mid-Century

In hospitals, medical and nursing disciplinary boundaries were clearly defined: nurses did not need to diagnose and prescribe. During the mid 20th century, the nursing profession was struggling to define itself and its disciplinary boundaries, especially in relationship to the profession of medicine. With the rise in medical technology, scientific progress in medicine and surgery, and the growth of hospitals after World War II, the majority of nurses worked in hospital settings rather than in private duty or public health nursing services. Nurses had ready access to medical supervision. In hospitals, medical and nursing disciplinary boundaries were clearly defined: nurses did not need to diagnose and prescribe.

With this as context, while nurses like those in the Frontier Nursing Service were working quite independently outside hospitals, often diagnosing patients’ conditions and dispensing drugs according to standing orders, in 1955 the American Nurses Association developed a model definition of nursing that would constrain the professional practice of nursing for the next several decades. The definition, published in 1955, emphasized the fact that nurses were neither to diagnose nor prescribe:

The practice of professional nursing means the performance for compensation of any act in the observation, care and counsel of the ill . . . or in the maintenance of health or prevention of illness . . . or the administration of medications and treatments as prescribed by a licensed physician . . . The foregoing shall not be deemed to include acts of diagnosis or prescription of therapeutic or corrective measures. (ANA, 1955, p. 1474)

While the ANA may simply have been seeking clarity in defining the discipline’s boundaries, its exclusion of the acts of diagnosis and prescription disrupted nurses’ autonomy in practice settings in which they had long been providing care. In addition to the work of the HSS and FNS nurses, this included nurses working for the Indian Health Service on remote reservations (Keeling, 2006; Keeling & Bigbee, 2005; Kirchgessner & Keeling, 2014). Since the mid 1920s, Indian Health Service nurses had been providing much of the care needed on those reservations, including holding well baby clinics; giving immunizations; and screening and treating patients for diseases like trachoma and tuberculosis. Now the ANA was challenging their expanded role. Moreover, the ANA’s restrictive definition of nursing and the restrictive stance of organized medicine over the boundaries of their discipline would set the stage for inter-professional conflict over nurses’ right to diagnose and prescribe. This conflict would come to a head with the inception and implementation of the nurse practitioner role in the 1960s and would continue into the 21st century (Safriet, 2002).

The Nurse Practitioner

In 1965, assistant professor of nursing Loretta Ford and pediatrician Henry Silver envisioned a nursing role that could “bridge the gap between health care needs of children and families’ ability to access and afford primary health care” (Ford, 1979, p. 517). The pair’s intent was to educate graduate pediatric nurses to provide healthcare services in rural clinics in Colorado, essentially expanding the nurse’s role in well-child care (Brush & Capezuti, 1996, p. 5). According to Ford: “I was well aware of the unmet health needs of people of all ages in the community and confident that nurses could be prepared to meet those needs by facilitating access and promoting continuity and coordination of care” (Ford, 1979, p. 517).

Grass roots physicians – especially those practicing in rural areas of the country --welcomed the Nurse Practitioner’s help, while organized medicine guarded their discipline’s boundaries. The nurse practitioner certification project was designed to prepare professional nurses to provide comprehensive well-child care and to manage common childhood health problems. The idea was that the nurse practitioner would work in a collaborative, collegial relationship with the physicians, and not as a physician substitute (Ford, 1997). It was a concept rooted in the roles of early 20th century visiting nurses, the Frontier Nurse Service, and the Indian Health service. As such, it was not that it was so new but that it was being redeveloped into a more formal, “certified” role for advanced nursing practice. The NP role would have specialized educational preparation, a new title, and the recognition it deserved.

The problem was, however, that the NP role would blur the boundaries of medicine and nursing – a role that would complicate matters and a role that would be questioned by both professions. Grass roots physicians – especially those practicing in rural areas of the country --welcomed the Nurse Practitioner’s help, while organized medicine guarded their discipline’s boundaries. Meanwhile, nurse faculty advocated instead for the advanced practice role of the Clinical Nurse Specialist, many arguing that NPs were acting as “junior” doctors (Fairman, 1999; Fairman 2002).

The Committee to Study Extended Roles for Nurses

The introduction of the nurse practitioner role set the stage then for critical examination of the profession’s boundaries... The introduction of the nurse practitioner role set the stage then for critical examination of the profession’s boundaries, and in the early 1970s, Health, Education and Welfare Secretary Elliott Richardson established the Committee to Study Extended Roles for Nurses. This group of healthcare leaders was charged with evaluating the feasibility of expanding nursing practice (Kalisch & Kalisch, 1986). The committee concluded that extending the scope of the nurse's role was essential to providing equal access to healthcare for all Americans.

According to a 1971 editorial in the American Journal of Nursing: “The kind of health care Lillian Wald began preaching and practicing in 1893 is the kind the people of this country are still crying for…” (Schutt, 1971, p. 53). The committee urged the establishment of innovative curricular designs in health science centers and increased financial support for nursing education. It also advocated standardizing nursing licensure and national certification, and developed a model nurse practice law suitable for national application. In addition, the report called for further research related to cost-benefit analyses and attitudinal surveys to assess the impact of the new role.

The committee also urged national certification for nurse practitioners, and developed a model nurse practice law that could be applied throughout the nation. In response, with mounting concern over the restrictive 1955 ANA definition of nursing practice, the ANA counsel suggested the following addendum to state nurse practice acts:

A professional nurse may also perform such additional acts, under emergency or other special conditions, which may include special training, as are recognized by the medical and nursing professions as proper to be performed by a professional nurse under such condition, even though such acts might otherwise be considered diagnoses and prescription. (Weiss, p. 28)

... the addendum’s meaning was clear—NPs could diagnose and prescribe... Despite the cumbersome language, the addendum’s meaning was clear—NPs could diagnose and prescribe—as long as these acts were done under “special” conditions. Defining these special conditions would be the next challenge. Meanwhile, the Committee to Study Extended Roles for Nurses also called for further research related to cost-benefit-analyses of the new role as well as attitudinal surveys to assess its impact. The end result was increased federal support for training programs for the preparation of several types of nurse practitioners, including Family Nurse Practitioners (FNPs), Adult Nurse Practitioners (ANPs), and Emergency Nurse Practitioners (ENPs), among others.

Sermchief v Gonzales, a challenge to NP Practice

Legal challenges to the NP role followed, as NPs began to practice at the full extent of their certification and licensure. Legal challenges to the NP role followed, as NPs began to practice at the full extent of their certification and licensure. In a 1980 landmark case, Sermchief v. Gonzales (1983), the Missouri medical board charged two women's healthcare NPs with practicing medicine without a license (Doyle & Meurer, 1983). The initial ruling was against the NPs, but on appeal the Missouri Supreme Court overturned the decision, concluding that the scope of practice of advanced practice nurses (APNs) could evolve without statutory constraints (Wolff, 1984). This case was the basis on which new state nurse practice acts addressed issues related to APN practice using very generalized wording, a change which allowed for expansion in APNs’ roles and functions.

Writing in The Yale Journal on Regulation in 1992, Associate Dean and Lecturer of Law at the Yale Law School, Barbara J. Safriet, urged immediate legislative reform to reduce the restrictions on advance practice nurses, particularly those constraining nurse practitioners and certified nurse midwives:

Although our ailing health care system presents an endless array of symptoms, the diagnosis is relatively straightforward: too few people can get good care when they need it and at a price they can afford. Any proposed cure should therefore include, at a minimum, steps to eliminate …those things that impede the efficient and effective provision of health care…. Chief among these are conflicting and restrictive state provisions governing the scope of practice and prescriptive authority of Nurse Practitioners and Certified Nurse Midwives, as well as the fragmented and parsimonious state and federal standards for their reimbursement. As a result of these provisions, NPs and CNMs are severely hampered – or disabled altogether – in their efforts to fulfill their fully proven potential to enhance our nation’s health (p. 440).

Conclusion

Twenty-eight years after the call in The Yale Journal on Regulation, the Institute of Medicine (to which Safriet served as consultant) would make nearly the identical recommendation in their report on the Future of Nursing, stating that “Nurses, and particularly advanced practice nurses, should work at the full extent of their training to provide timely, efficient, and cost-effective care to people across the United States” (IOM, 2010, p. 3-1) An expanded role for nursing is an idea deeply rooted in nursing’s past and from it, much can be learned for today. Indeed, nurses should take this historical opportunity to think creatively about recycling elements of past practice for today’s unique context – perhaps initiating state–of-the-art nurse-run clinics in rural and inner city areas; reaching others by telenursing; and collaborating with designers in technology firms to create Apps and other high tech solutions to bridge gaps that exist in healthcare today.  To do so, they must first read and understand the impact of the historical antecedents, cornerstone documents, and legislative acts that contribute to the nursing profession’s rich history.

Author

Arlene W. Keeling, PhD, RN, FAAN
Email: awk2z@virginia.edu

Arlene Keeling, PhD, RN, FAAN is the Centennial Distinguished Professor of Nursing at the University of Virginia School of Nursing in Charlottesville, VA. She is director of the Eleanor Crowder Bjoring Center for Nursing Historical Inquiry, and Department Chair of Acute and Specialty Care.  Dr. Keeling is author of Nursing and the Privilege of Prescription (Ohio State University Press, 2006); and co-author of Nurses on the Frontline (Springer, 2011) as well as Rooted in the Mountains, Reaching to the World (Butler Books, 2012). She has recently authored The Nurses of Mayo Clinic (Mayo Clinic, 2014) and co-authored Nursing Rural America, 1900-1950 (Springer, 2014). Dr. Keeling serves as co-chair of the Expert Panel on History of Nursing and Health Policy, the American Academy of Nursing.

References

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Registration of Nurses, 126th Session, Laws of New York. Section 206, 599, (1903)

Executive Committee of the Henry Street Vising Nurse Service. (n.d.) Bylaws. Retrieved from the Lillian Wald Collection, (Columbia University, box 42, folder 6, p. 3)

Brush, B. & Capezuti, E. (1996). Revisiting a nurse for all settings: The nurse practitioner Movement, 1965-1995. Journal of the American Academy of Nurse Practitioners 8(1) 5-11.

Cockerham, A. & Keeling, A. (2012). Rooted in the mountains, reaching to the world: Stories of nursing and midwifery at Kentucky’s frontier school, 1939-1989. Louisville, KY:Butler Books.

Doyle, E., & Meurer, J. (1983). Missouri legislation and litigation: Practicing medicine without a license.  Nurse Practitioner, 8: 41–44.

Duffus, R. (1938) Lillian Wald, Neighbor and crusader. New York, NY: Macmillan

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Fairman, J. (1999) Playing doctor?: Nurse practitioners, physicians and the dilemma of shared practice, The Long Term View, 4, 27-35.

Frank v. South, 175, Ky. 416, 194 S.W. 375 (1917).

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Ford, L. (1997). A deviant comes of age. Heart and Lung, 26(2), 87-91

Frontier Nursing Service. (1948). Medical routines for the use of the staff of the frontier nursing service. (4th ed). University of Kentucky, Archives.

Harrison Narcotic Act, (1914)

Hilts, P. (2003). Protecting America’s health: The FDA, business and one hundred years of regulation. New York, NY: Knopf.

Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Retrieved from http://books.nap.edu/openbook.php?record_id=12956

Kalisch, B. & Kalisch, P. (1986). The advance of American nursing. (2nd ed). Boston, MA: Little, Brown and Company

Keeling, A. (2006) Midway between the Pharmacist and the Physician: The work of the Henry Street Settlement Visiting Nurses, 1893-1944. In Nursing and the privilege of prescription: 1893-2000 (p. 1-27). Columbus, OH: The Ohio State University

Keeling, A. & Bigbee, J. (2005) The history of advanced practice nursing in the United States. In A. Hamric, J. Spross, & C Hanson (Eds.) Advanced nursing practice: An integrative approach (p.1-21) Philadelphia, PA: W. B. Saunders Co.

Kirchgessner, J. & Keeling, A. (2014).  Nursing rural America, 1900-1950. New York, NY: Springer Publishing.

Medical Advisory Committee. (1928) Medical Routine for Use of the Frontier Nursing Service Lexington, KY.

Safriet, B. J. (1992). Health care dollars and regulatory sense: the role of advance practice nursing. Yale Journal on Regulation, 9(2), 417-488.

Safriet, B. J. (2002). Closing the gap between can and may in health care providers’ scopes of practice: A primer for policymakers. Yale Journal on Regulation. 19, 301- 334.

Schutt, B.G. (1971) Editorial: A profit honored. American Journal of Nursing, 71(1), 53. Retrieved from http://journals.lww.com/ajnonline/toc/1971/01000#374826894

Wald, L. (1901-02). The nurses’ settlement, official reports of societies, American Journal of Nursing, 2, 386-87

Willeford, M.(1932) Income and health in remote rural areas: A study of 400 families in Leslie County Kentucky. New York City, NY: FNS Inc.

Willeford, M. (1935). Organization and supervision of the field work of the FNS, Inc. Quarterly Bulletin of FNS, 7-8

Weiss, J., (n.d.) Nursing practice: A legal and historical perspective, Journal of Nursing Law 2(1) , 17-35. 


© 2015 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2015


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