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. 2022 Mar 31;29(4):e12490. doi: 10.1111/nin.12490

Revealing historical perspectives on the professionalization of nursing education in Norway—Dilemmas in the past and the present

Vibeke Narverud Nyborg 1,✉, Sigrun Hvalvik 1
PMCID: PMC9787650  PMID: 35362190

Abstract

The professionalization of modern nursing education from 1850 and forward is closely linked to values and virtues underpinned by Christian ideals, sex‐based stereotypes and class. Development in the late 19th century of modern hospital medicine, combined with a scientific understanding of antisepsis and asepsis, hygiene, contagion prevention and germ theory, were highly influential insights to the dominant position of modern medicine in health care. This development constituted a key premise for what nurses, by virtue of being women, and combined with their education, could offer in terms of medical assistance. It enabled them to challenge the prevailing sex‐based stereotypes‐ and class‐based hierarchies, allowing modern nursing to retain aspects of both traditional Christian and womanly values, while at the same time adhering to the medical science paradigm. In this paper, we argue that modern nursing education developed in a context characterized by traditional female and religious values, while at the same time being increasingly dominated by the influence of scientific and medical progress. This conflict between traditional and modern values caused dilemmas and tensions as the nursing profession developed. We argue further that similar dilemmas and tensions continue to pervade contemporary nursing and nursing education.

Keywords: education, historical nursing values, history of health, history of nursing, nursing, professionalization

1. INTRODUCTION

Nursing is one of the core professions in modern health care systems. Historically, it has been associated with the values of charity, compassion, self‐sacrifice and mercy—values that are associated by women as primary caregivers throughout history, and which are still associated with nursing today. However, nursing's traditional values were challenged throughout the 18th, 19th and 20th centuries as the profession adapted to modernization processes. Modernization brought nursing closer to the medical profession, placing new demands on nurses in response to technical and scientific developments. Contemporary nursing is also facing tensions and dilemmas resulting from conflicting values. Traditional values that emphasize holistic care are still embedded in nursing education, and in practical care settings, the education of nursing students is strongly influenced by ideologies derived from concepts such as evidence‐based medicine (EBM) and new public management (NPM) (Bondevik & Engebretsen, 2017, p. 449; Kleiven et al., 2016). As demonstrated by recent research (Christiansen & Bjørk, 2016; Kleiven et al., 2016; Martinsen, 2014), such value conflicts can sometimes be difficult to reconcile.

In exploring the early stages of the professionalization of nursing education, we can draw parallels to contemporary challenges, while at the same time acknowledging that both values and virtues change as society progresses and develops. What appears to stand out as a recurring issue throughout the evolution of nursing education is that contextual developments in society at large have been, and still are, regarded as a threat to the principle of holistic care and that this issue continues to receive great emphasis within nursing and nursing education.

2. BACKGROUND AND AIM

From the very beginning of the professionalization of nursing, nurses have been faced with conflicting sets of values. Traditional vocational values that emphasize a holistic approach to the care of individual patients have come up against the values of science and modern medicine, where the focus is directed on protecting society from disease based on principles of efficiency and rationality. Both sets of values must be regarded as significant components of modern nursing's knowledge base, and hence also on nurses' ability to practice holistic care. Based on a theory that links the image of health care professionals to their belonging objectives with factors that contributed to their important role in society (Larsen, 2014, pp. 103–106), we can postulate that while medical doctors during the 19th century were interested mostly in scientific developments and the fulfilment of their objectives towards the benefit of society, nurses were concerned mostly with their role as caring supporters focused on the individual. Their dilemma was having to balance societal needs with their own professional autonomy (Nyborg, 2021, p. 167).

In this paper, we will argue that womanly and religious values and virtues were given the greatest emphasis during the early stages of modern nursing education. Our exploration of these values and virtues will be centred on addressing three questions: (1) What did it mean to be a competent, professional nurse in the early years of nursing education? (2) How did prevailing societal views on women influence early nursing education and the development of professionalized care? and (3) What virtues were emphasized in early nursing education as safeguarding high levels of commitment to the job and autonomous professional development? Such knowledge will provide insight into dilemmas that arose during the professionalization process, and which continue to give insights into understanding dilemmas that still arise in today's nursing.

We have adopted a historical hermeneutic approach to our analysis of the first textbooks used in Norwegian nursing education. We have also drawn from discussions on nursing education that appeared in early 20th century journals as a means of highlighting the areas of focus that prevailed at this early stage in the professionalization of nursing in Norway. We will also address how this related to trends and developments elsewhere in the world, which in turn will help to place the textbooks in a global context (Jordanova, 2006; Kjeldstadli, 1992). Results from previous research conducted by Norwegian and international historians of nursing have been used to frame our analysis, adhering to the principle of regarding human actions as part of the totality of historical events (Schiøtz, 2000).

3. RESEARCH IN THE HISTORY OF NURSING

Research into the history of nursing education appears to have progressed along two distinct paths. The first has focused on the religious nursing tradition, originating from monastic practices (Nelson, 2003) and the deaconess tradition that evolved in the German city of Kaiserwerth (Hvalvik & Moseng, 2014). The second path has emphasized the more secular traditions that originated from the nursing training systems established by Florence Nightingale at St. Thomas' Hospital in London (Nielsen, 2005; Schiøtz, 2017, pp. 325–328). Extensions of these paths have served to frame very specific narratives of early modern nursing and nursing education. The first of these narratives is centred on the image of the nurse as an obedient and self‐sacrificing assistant to the doctor, while the second is embedded in the idea of the nurse as an autonomous professional who challenged the absolute professional power held by the doctors (Schiøtz, 2017, p. 328). Both narratives explore important considerations such as sex‐based stereotypes, power, social class and professionalization. We believe, however, that the extent to which these narratives shed light on the complexities involved in the development of modern nursing is open to discussion. In this paper, we will attempt to broaden these two narratives and in doing so contribute to a wider understanding of the complexities involved in the development of nursing education by exploring the dilemmas encountered by the profession during its evolution.

Anne Marie Rafferty has examined these dilemmas at the macro level and has studied and summarized the issues that have preoccupied most researchers in the history of nursing in recent decades. Rafferty recognizes three macro themes to evolve: religion, war and politics (Rafferty, 2014). In a Norwegian context, the history of nursing has recently emerged as a significant field of research, and in recent decades historians have delivered interesting work on the subject from a national perspective (Adriansen, 2017; Fause, 2017; Hvalvik, 2005, 2011; Hvalvik & Moseng, 2014; Melby, 1990; Moseng, 2012). In comparing developments in Norwegian nursing education to practices overseas, we find that two themes in particular—religion and politics—resonate with the macro themes highlighted by Rafferty. In this paper, we have used these themes to contextualize our exploration of the professionalization of early nursing education.

We will continue by placing nursing in the context of the modernization processes that took place within wider society as the profession evolved and show how different textbooks used in Norwegian nursing education was written and adapted to the development in both education and society at large. We will follow this with an in‐depth historical exploration of the appearance of specific prerequisites that can be linked to the values and virtues inherent in the professionalization of modern nursing and nursing education. We will use mainly Norwegian examples in our analysis, but believe strongly that our perspectives may also be of relevance in international contexts, not least because the evolution of nursing as a profession has been driven by collaborative efforts carried out across both Europe and North America (Hvalvik, 2005, pp. 205–210, 217–218).

4. CONTEXTUALIZING EARLY NURSING EDUCATION AND THE EMERGENCE OF NURSING TEXTBOOKS

The professionalization of nursing is understood by historians as a 19th‐century construct, and must thus be viewed in an appropriate societal context (Moseng, 2014b, pp. 597–563). Throughout the 19th century, we observe a transition in the health care arena in Norway as in many other European countries, where the professional sector started to expand at the cost of the folk sector (Kleinman, 1980, pp. 24–27, 59–60). Health became a responsibility of the state, and not the concern of individuals. Part of this transformation must be understood in light of what we know about the prevailing expert knowledge and formal education (Nyborg, 2021, p. 95, 105). During the 19th and 20th centuries, the provision of health care services became key to the construction of a modern and healthy society, and the professionalization of health care providers was an important step on the road towards achieving this aim (Alver, 2013). The changes towards a modern society were associated with three major developments: the industrial revolution, and the ongoing revolutions in science and democratization (Hagemann, 2005). Developments in medicine, such as the building of hospitals and a better understanding of antisepsis and asepsis, hygiene, contagion prevention and germ theory, must be seen as extensions of these societal revolutions and contributed to the increasing influence of medical science in health care. The shaping of nursing as a profession and the formulation of the ideas, values and virtues that were considered essential to nursing education thus took place in the context of these revolutionary tendencies and contributed to the construct of modern nursing.

The first nursing education in Norway was established in accordance with the Kaiserwerth model at the Deaconesses' house (Diakonissehuset) in 1868. Subsequently, an auxiliary Red Cross Nursing School was established in the Norwegian capital Christiania, now Oslo, in 1895. Here, less emphasis was placed on a woman's religious vocation, although the value system continued to be rooted in humanistic and holistic approaches to care (Hauge, 1996, pp. 38–39). During subsequent decades, a wide range of nursing education programmes appeared, both religious and secular, and succeeded in educating a large number of skilled nurses. (A list of nurses educated in the various nursing programmes offered in Norway was published in the journal ‘Sykepleien’ in 1912. In the period between 1868 and1911, the list included approximately 1000 nurses.). These programmes varied widely in terms of the content and duration of the education they offered.

In Norway, at this time, there was no established national curriculum or universal agreement as to the theoretical and practical content of nursing education. However, we know et least three nursing textbooks were in use in nursing education in Norway between 1868 and 1940 (mentioned in Sykepleien no. 10, August 1913; Sykepleien no. 1, January 1918). Together with the Norwegian Nursing Association's (NSF) curriculum, which appeared in 1917, the three textbooks made up the foundation of both theoretical and practical knowledge of nursing, offer us normative access to explore why certain values and virtues were assigned special emphasis as part of the early education. Two of these three textbooks were written and used in accordance with the first professional nursing educations. The first textbook was written by Deaconess Ulrikke Eleonore Nissen in 1877, and the extent of its publication and use was much greater than could have been expected (Martinsen, 1984, pp. 137–140). Nissen's short first chapter is dedicated to the professional nurse and sets out the values and attributes to which Nissen believed a nurse should aspire. The values described are closely linked to the concept of religious vocation, which Nissen regarded as the primary force behind becoming a nurse (Nissen & Martinsen, 2000). Nissen's remaining chapters are dedicated to practical nursing.

The second textbook was written by doctor Hans Riddervold Waage in 1901 and ran to several editions (Martinsen, 1984, p. 140). This book was written when secular nursing education programs emerged in addition to the education from the Deaconess House. The book was referred to in the nursing journal Sykepleien and reviewed in detail in the Norwegian Medical Journal in 1907. The first chapters of the book emphasize a nurse's duties and the essential attributes and characteristics that a nurse must possess (Waage, 1901, pp. 14–17). These were followed by later chapters addressing anatomy and physiology, and finally focusing on practical nursing.

The NSF was founded in 1912, and in its first years was quick to raise the issue of a curriculum and a formal 3‐year professional nursing education (Hvalvik, 2005, p. 118). In spite of these efforts, a regulated national three‐year nursing education programme was not put in place before and after the Second World War. However, several new nursing educations emerged and called for new and more modern textbooks. The third textbook was hence written to meet the demand of a textbook adapted to the developments NSF argued for concerning a 3‐year education. The two doctors Kristian Grøn and Sofus Wiederøe edited the third book in 1921 (Grøn & Widerøe, 1932). A second edition was published in 1926, printed again in 1932. Superintendent nurse Andrea Artnzen wrote an introduction to the book, as well as a chapter on the duties and qualities required of a nurse. Mrs. Aagot Lie wrote a chapter on practical nursing. There were also chapters written by specialist doctors giving accounts of their respective fields of expertise (Grøn & Widerøe, 1932, preface). The book was written in response to requests from teachers at one of the hospitals offering nursing education in the capital, who 'lacked access to a textbook that focused on the principles of modern nursing' (Grøn & Widerøe, 1932, preface). The book also addressed specific societal challenges related to medicine and health and reflected a new approach to the role of nursing in the context of public health (Grøn & Widerøe, 1932, p. 2).

Although the three textbooks were somewhat different, they combine to give a clear illustration of a developmental trend towards modern nursing that reflected prevailing public health issues such as combating epidemic disease by means of hygiene and other preventive measures (Schiøtz, 2003, pp. 92–95). We can trace certain similarities in terms of the values, virtues and attributes to which a nurse should aspire. Nissen's book emphasizes the importance of religious vocation, and as such reflects the deaconess' tradition. In Waage's book, Nissen's autonomous nurse is reduced to a subservient assistant to the superior doctor, with the job of nursing seen as more of a way of life than a religious call to care (Waage, 1901, p. 14). Grøn and Wiederøe's book must be recognized as making a great stride towards re‐establishing the status of nursing as an autonomous profession, in contradiction to Waage's view. It also demonstrated that the theoretical basis for the practice of nursing was expanding and becoming firmly embedded in contemporary medical knowledge (Grøn & Widerøe, 1932, pp. 29–35, 83–100, 183–204).

Researcher Ann Bradshaw has studied the same issues from a British historical perspective and has identified four aspects highlighted in British nursing textbooks that define the qualities required to become a good nurse: (1) moral character, (2) appropriate skills, (3) learning by the example of a superior nurse and (4) the formation of appropriate relationships with patients (Bradshaw, 2000). We recognize similar qualities set out in the aforementioned Norwegian textbooks and believe that these came into conflict with requirements placed on the nursing profession as part of the modernization processes from the beginning of the 20th century.

From the second half of the 19th century and up to the inter‐war period, society exhibited high levels of optimism, which were sustained in the professional health sector by rapid developments in medical science and associated technological developments (Hvalvik, 2011). In the wake of developments in laboratory medicine, the prevailing medical paradigm changed from a holistic to a more science‐based and reductionist outlook. This change was closely linked to the rationalist ideas of Descartes, who divided the human body into two different substances: a material res extensa and a non‐material res cogitans (Schiøtz, 2019, p. 13). Consequently, the shift in the medical paradigm exerted a major influence on the nature of nursing education, both in terms of theoretical and practical training, and in so doing also impacted on how the occupation of the professional nurse was actually defined. However, in spite of developments towards the creation of an autonomous and modern profession, it remained important among nurses themselves to defend traditional values such as compassion, self‐sacrifice and holistic care. As is asserted by nursing historian Sigrun Hvalvik (Hvalvik, 2011), these fundamental values incorporated traditional and closely related womanly and vocational ideals. Change in light of these developments allows us to understand some of the dilemmas that were about to emerge in the profession at the intersection between traditional and religious‐based vocational nursing and the sociopolitical aim of securing a healthy population based on new medical ideas and scientific developments.

5. NURSING EDUCATION: EXPLORING PAST VIRTUES AND VALUES

It is important to bear in mind that society during this period was governed by ideals promulgated mostly by men, and that the professional health care sector was characterized by significant sex segregation: doctors were men and nurses were women. Contemporary views on women and their capabilities were defined exclusively by men (Schiøtz, 2017, pp. 293–294), and many doctors wished to control the development of nursing education to suit their own needs. It was indeed argued by some doctors that too much theoretical knowledge was wasted on nurses. One example was the aforementioned Doctor Waage, who presented his views on the relationship between nurses and doctors in a newspaper article in 1913, and summarized in two important points: first, nurses must always be obedient to their doctors, and second, excellence in nursing should be the result more of personal ability than of theoretical knowledge as quoted in the journal Sykepleien in 1913. Disagreements regarding both the profession of nursing and nursing education created tensions between nurses and doctors, and these were exacerbated by the increasing modernization and specialization within the health care sector in step with other segments of society (Helmstadter, 1997; Moseng, 2008). Long‐established hierarchical structures continue to fuel such tensions today. While sex and sex‐based stereotypes played an important role in the past, current tensions between doctors and nurses are more likely to be linked to the power inherent in knowledge and the levels of responsibility held by the respective professions within modern health care institutions (Elstad, 1991). In Norway, this issue has recently been the subject of debate in connection with the implementation of Advanced Practitioner Nurse Education programmes (Sivertsen, 2019). The debate reveals that this kind of education might disrupt the established power balance and contribute to problematizing task shifts between professions as a result of more education and more responsibility.

The historical tensions between doctors and nurses demonstrate that nurses have continued to encounter conservative attitudes on several levels in their struggle to achieve adequate education and autonomy in their profession. Nurses have always recognized the necessity to modernize in step with advances in health care services and developments in wider society. This has meant finding a balance between the traditional values of humanistic and holistic care, and the demands of an evolving and increasingly dominant medical science paradigm.

We have already argued that nursing education emerged initially from a holistic understanding of care based on womanly attributes and the religious tradition, values often associated with the good Samaritan. Further that the nursing profession developed as much in the wake of modern medicine as of holistic care. Once nursing care became professionalized, it was no longer viewed as something that any woman could carry out. Professional nursing required an education incorporating both theoretical and practical knowledge that could respond to the needs of both the patient and society at large. It can be argued that these objectives, the patient and society, can be seen as extensions of the contrasting values highlighted earlier in this paper: a holistic caring tradition focusing on the individual patient, and a scientific medical approach directed towards society. We argue that a recognition of this dichotomy is the key to any understanding of how professional nursing was shaped and framed throughout history and that similar tensions can be identified in Norway today as nursing adapts to EBM and NPM while also trying to maintain a focus on holistic patient care, emphasized by a newly developed framework such as person‐centred nursing (McCormack & McCance, 2006).

6. DEVELOPING PROFESSIONAL COMPETENCE

From the mid‐19th century, professional competence and knowledge in health care were regarded as essential to safeguarding a healthy population. Carol Helmstadter is one of several nursing historians who claim that during the 19th century, the work of unskilled orderlies and their possible negative impacts on the care and safety of patients was of major concern to doctors all over Europe. The same has been argued by historian Ole Georg Moseng in a Norwegian context (Moseng, 2012, pp. 49–51). The solution to this problem was the training of professional nurses (Helmstadter, 2002). As a result, during the late 19th and early 20th centuries, demands for trained nurses in hospitals, as well as in private care and rural settings, increased all over Europe (Hvalvik, 2005, pp. 70–71; Kaurin, 1879, preface).

In this paper, we also argue that the emergence of professional competence and professionalized care effectively separated the skilled nurse from the unskilled orderly and represented one aspect of the ongoing advances within the nursing profession itself. The state of being professionally competent must also be recognized as deeply contextualized and influenced by societal values as much in the past as it is in the present.

Nursing schools were established to produce skilled nurses who could contribute to a healthy population based on their professional competence. Nursing would no longer be an occupation for unskilled women looking for a job outside the home. Professionalization was accompanied by the emergence of Norwegian and international nursing journals that reinforced the importance of being professionally competent. In Norway, the journal ‘Sykepleien’ provided its readers with new knowledge and an awareness of international developments in nursing education, based primarily on the work of the International Council of Nursing's (ICN) education committee. Contributions from Swedish, Danish, British and American authors were published, including discussions about what knowledge professional nursing required, and how nurses should be trained to fulfil their role. Areas in which international nursing correlated with the Norwegian understanding of professional competence in education were connected primarily to a shared awareness of the importance of combining theoretical knowledge with the history of nursing and ethics. The international curriculum published by the ICN in 1930, and the work of the NSF in Norway, combined to safeguard key principles derived from the Nightingale tradition, such as the importance of autonomous nursing management in education and preliminary courses for women that wished to attend nursing schools. (Hvalvik, 2005, p. 215). Today, nursing continues to exhibit an international focus, but the homogenizing approach that held sway during the early stages of international collaboration has now been replaced by a variety of educational programmes and specializations, as well as contrasting approaches to nursing research. This diversity can be seen both as a challenge to the retention of traditional nursing values and also as an opportunity to further reinforce nursing as an autonomous profession. Insight into past dilemmas within the profession may help us to deal with the challenges this diversity can cause.

Both in terms of theoretical knowledge and practical skills, it was the vocation, or calling, that continued to form the foundation upon which nurses built their professional competence, and thus legitimized their existence as professional caregivers (Grøn & Widerøe, 1932; Nightingale, 1898; Nissen & Martinsen, 2000; Waage, 1901). Once the value of the vocation and traditional values started to come into conflict with scientific developments in medicine, discussions quickly arose as to what professional competence in nursing really meant. In Norway, the major discussions during the early stages of professional nursing were related to the duration and content of a nurse's education (Moseng, 2012, pp. 181–183). Moseng argues that the time taken to educate an autonomous professional nurse has been the object of a major struggle between nurses and doctors ever since 1918 (Moseng, 2012, p. 182). Much was at stake because the NSF was fighting determinedly for the very essence of autonomous nursing, including the incorporation of high levels of qualitative, holistic care. Similar discussions are taking place today, for example, the already mentioned debate regarding the implementation of the Advanced Nurse Practitioner Education Programme. The discussion has arisen on regular basis between then and now.

More than 40 years ago, Martinsen and Wærnes (1979) described a ‘crisis in care’ arising from progressive specialization in the health care sector that promoted a fragmented approach to the patient (Martinsen & Wærness, 1979, pp. 8–9). They suggested that an insight into the historical development of nurses' struggles for autonomy and recognition would be crucial to addressing the challenges that they observed during the 1970s (Martinsen & Wærness, 1979, p. 9, pp. 102–104). Three decades later, a systematic analysis of policy documents and government guidelines related to Norwegian nursing education for the period 1921 to 2019 shows that the concept of ‘care’ has occupied only a very minor place in nursing education (Petersen & Boge, 2020). This is in spite of the fact that the NSF has tried to argue that nursing education needs to develop its own set of values and logic that are distinct from those embedded in a purely medical approach (Petersen & Boge, 2020). It may be argued that a common thread running through both the past and present dilemmas is how nurses have tried to balance a variety of contextual challenges that have, in their different ways, threatened the principle of holistic care for the patient. Further analysis in the wake of these perspectives is vital to get a deeper understanding of how EBM, and a standardized approach to health, can be viewed as a threat, but also contribute to the exercise of holistic care.

The developments in nursing over the last 40 years, with the establishment in academia and extensive research in nursing and nursing‐related topics, have contributed to questioning the meaning and construction of, for example, the concept ‘holistic care’ in a nursing context (Watson, 1985). Such research and meaning‐making processes of central concepts in nursing are important to enable nursing as a profession with its own conceptual framework. An important premise when different nursing specializations affect both the directly and indirectly tasks of care in different health care services is mentioned in the work by Martinsen and Wærnes when they described a ‘crisis in care’ (Martinsen & Wærness, 1979, pp. 105–110). Here, Martinsen and Wærnes were concerned about how other professions had taken over the immediate care of the patient, while nurses worked more secondarily with care. In this way, we can see how an understanding of care changes in relation to developments within nursing and in the context, care is carried out.

7. TRADITIONAL VALUES AS BASIS FOR PROFESSIONAL CARE?

We have already described traditional values in nursing as embedded in womanly and Christian values. The religious vocation that was characteristic of the deaconesses' tradition had a great impact not only on the development of early approaches to nursing education but also on early meanings of the concept of modern professional nursing. This is reflected partly in the idea that those women who applied to nursing schools could not expect to become good nurses unless they saw their occupation as something greater than the practical performance of their day‐to‐day duties. A woman's personal qualities were looked at as crucial factors in terms of her admission to nursing school. All the early textbooks explicitly highlighted characteristics such as cleanliness, reliability, courtesy, compassion and obedience as highly desirable for any woman who wished to become a nurse. They were fundamental to the life that a nurse should lead, both professionally and privately, and would ultimately give her the strength necessary to see her vocation to care for her patients as something more than just an occupation (Grøn & Widerøe, 1932; Kaurin, 1879; Nissen & Martinsen, 2000; Waage, 1901). Nursing education and the meaning of modern nursing were thus closely linked to Christian beliefs and womanly virtues, both of which contributed significantly to the prevailing understanding of professional competence.

There may of course have been several reasons why such attributes were highlighted and some of them, such as compassion, obedience and courtesy, arose simply from the Christian tradition of obedience to God by performing charity and offering help and care to those in need (Nutton, 2006, p. 55, 70). Vocations to self‐sacrifice and the aim of helping others in need, despite their faults or disease, can be traced back to early Christianity, and manifested often reflected the strict duties set out in rules governing the early monasteries (Fause & Micaelsen, 2001; Wyller, 1978). The tradition was continued and maintained in the early nursing schools and underpinned specific requirements for nurses to exhibit attributes such as reliability and obedience, despite that the religious connection eventually was toned down. Such virtues and values served to separate educated nurses from the unskilled orderlies, who were increasingly seen as a threat to patients' health and safety (Helmstadter, 2002; Moseng, 2012).

Doctor Waage was one of the first explicitly to challenge the importance of a religious duty to care for others and in doing so contributed towards establishing a different direction for nursing education. Although Waage worked part‐time at the deaconesses' motherhouse in Norway (Martinsen, 1984, p. 140), he wanted to shift a nurse's primary focus away from her Christian duty. Effectively, he wanted a nurse's obedience towards God to be transferred to professional doctors. For Waage, theoretical knowledge was important, if only to the extent that nurses should be able to provide key and consistent information about patients and their conditions to the doctors. He remained wary however, observing that:

the pupils one is working with are in general somewhat differently equipped when it comes to intelligence… (Waage, 1901, preface).

Waage is expressing here nothing that would distinguish him from other men, and especially those from the upper classes, in terms of prevailing attitudes towards women and their capabilities (Schiøtz, 2003, p. 2, 79,  pp. 158–160). The opinions of upper‐class doctors represented one of society's gold standards. The desirable attributes of women who wished to become good and professional nurses were obedience, trustworthiness and understanding (Grøn & Widerøe, 1932; Nissen & Martinsen, 2000; Waage, 1901). However, these conventional and sex‐based stereotyped perspectives were also reflected in the education of nurses. Whether from the religious or the more secular schools, nurses based their values on a traditional societal outlook when it came to women (Hvalvik, 2004). As we have argued above, it was not only their competence that separated educated and professional nurses from the unskilled orderlies but also their support of traditional upper‐class and womanly ideals.

In general, doctors supported the education of professional and skilled nurses, but they were extremely conservative when it came to their assessments of what tasks women were suited to and what they could and could not acquire in terms of theoretical knowledge (Moseng, 2014a). We can only assume that these attitudes had a major impact on nurses and contributed to the dilemmas they faced as they worked to achieve a modern education system and assume their roles as autonomous professionals.

Paternalistic attitudes ran deep in both the health and education sectors (Hvalvik, 1996). Carol Helmstadter and Eva Gamarnikow have, in separate publications, given accounts of this from a British perspective, pointing to the fact that both sex and class played a significant role in the struggle between doctors and nurses during the development of professional nursing (Gamarnikow, 2016; Helmstadter, 2002). Although little research has been carried out into these issues in Norway, we do possess sources that support the influence of these sex‐based stereotype perspectives in this field. Professors at the School of Medicine, at the Royal Frederik University (the only University in Norway at that time), made the following statement when the Ministry of Religious Affairs was commissioned to explore the possibility of permitting women to study at the university in 1881. The professors all agreed that:

…no women should have access to study medicine. However, women have attributes that make them particularly skilled at proper nursing, a field for which nature has ideally equipped them (Schiøtz, 2017, p. 294).

Another factor was the issue of class. Differences in the backgrounds of aspiring students during recruitment to nursing education can serve as an example of what social class meant in terms of professionalization. To meet the standards required by a society of a professional nurse, all students had to be trained to adhere to an appropriate set of common values, virtues and beliefs that were in line with the applicable ideas of the time. In Norway during the early years of modern nursing, nurses came from more diverse backgrounds than other professions (Hvalvik, 1996, p. 57, 83; Moseng, 2012, pp. 73–76). Success in professionalization depended on the extent to which the schools were able to educate nurses that supported the values and virtues that were accepted by society. Student nurses thus had to internalize these attributes as part of their personal lives.

Historical documents provide an excellent picture of prevailing views as to the values to which professional nursing should adhere. Lady Superintendent Annie Gill at the Royal Infirmary of Edinburgh claimed that ethics was 'the science of morals' and linked this understanding to a nurse's behaviour and character. Gill claimed that acceptable behaviour could be learned, and emphasized the importance of specific virtues such as moral behaviour and good manners (Hvalvik, 2005, p. 59). The Norwegian nurse Andrea Arntzen made a similar statement to her colleagues:

Those who are lethargic, who are pleased to get through the day and happy when the day is done, will never amount to anything. That kind of nurse will bring the calling into disrepute (Grøn & Widerøe, 1932, p. 9).

These examples serve to underline the extent to which ‘proper’ upper‐class and prevailing values dominated early nursing education and the degree to which this was reinforced by senior nursing professionals. Commitment to the profession constituted an extension of these values, and failure to adopt them could be viewed as a hindrance to professional development. The proper set of values and virtues guided the nurse in her work and gave her the strength to remain committed to the job and deliver high‐quality care. In light of this, a discussion arises as to what extent a nurse's personal life was seen as a reflection of the care she delivered. It also constitutes one of the reasons why womanly virtues were so closely connected to historical understandings of professional nursing, and why such virtues formed an important part of nursing education in the early textbooks.

As we have argued previously, nurses' contribution towards the development of an autonomous profession has historically always been in response to demands for modernization made by society during the late 19th and early 20th centuries. This process was also influenced by doctors who wished to retain control of both nursing education and women in general, locking both into an adherence to traditional values centred on caring and sex‐based stereotypes perspectives. Since the start of the 20th century, the modernization and professionalization of nursing have been closely linked to developments in medicine and medical science. As we have argued in this paper, this phenomenon has challenged the idea of holistic care, both in theory and in practice. We argue also that value conflicts continue to generate tension in nursing and nursing education within health care institutions today. Nursing students in Norway study within a context of EBM, the natural sciences, generalization and efficiency. At the same time, they are told that their first responsibilities are to the patient and the exercise of person‐centred care. Our historical knowledge has shown that nursing education has been moving within this field of power politics since the establishment of modern nursing in the late 19th century.

8. CONCLUDING REMARKS

We have argued that certain values and virtues were constantly emphasized during the early periods of nursing education. In this paper, we have focused on an understanding of professional competence and how throughout history prevailing class‐ and sex‐based ideologies have influenced the perception of competence in nursing. We have also claimed that senior nurses made attempts to balance the traditional and modern values as nursing education progressed. Historically, the construct of modern nursing has repeatedly been caught at the intersection between traditional nursing values and modern scientific values and ideals. This has naturally influenced the content of nursing education programmes.

Professional competence as defined in early nursing education was strongly linked to clear views about the values and virtues to which a nurse should aspire, and how nurses should live. Historical textbooks placed great weight on the key attributes of professional competence and the need for nurses to exhibit a clarity of values and virtues. They are also preoccupied with supporting the notion that nurses shall exhibit commitment to the job, legitimized by a vocation of care. These prerequisites are also described as desirable in aspects of nursing education that promote holistic and person‐centred care in modern contexts (McCormack & McCance, 2017, pp. 41–46).

To make nursing recognized as an autonomous profession, nurses had to ally themselves to modern medical science, while at the same time adhering to their traditional values. This alliance created a number of dilemmas. Despite the fact that modern nursing is far more heterogeneous than ever, with qualifications available in Norway and overseas at both bachelor's and master's levels, nurses and nursing education continue to encounter dilemmas that may be argued to be rooted in history (Group & Roberts, 2001). Our current advances in knowledge in the field of health as embodied in both EBM and Person‐Centred Healthcare appear to lean on the same science and humanist traditions that were responsible for past tensions. Moreover, societal developments in recent decades, such as the implementation of the NPM initiative into health care policy and practice, both influence and threaten nurses' incentives to uphold fundamental values linked to the holistic care of their patients. We believe that reviewing nursing education from a historical perspective enables us to demonstrate how contextual developments in society through time have reinforced the need to maintain the traditional nursing value of providing holistic care to the patient despite that both care and holism as concepts continue to develop within new nursing contexts.

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.

ACKNOWLEDGEMENTS

The authors would like to thank two anonymous reviewers for their comments to improve the paper before acceptance. This paper was funded by the University of South‐Eastern Norway.

Nyborg, V. N. , &  Hvalvik, S. (2022). Revealing historical perspectives on the professionalization of nursing education in Norway—Dilemmas in the past and the present. Nursing Inquiry, 29, e12490. 10.1111/nin.12490

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are openly available in the National Library in Norway (https://www.nb.no/and) and the National Archive in Norway (https://www.arkivverket.no/).

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are openly available in the National Library in Norway (https://www.nb.no/and) and the National Archive in Norway (https://www.arkivverket.no/).

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