The Evolution of Nursing for Older Adult: A Historical Perspective

Nursing for older people has undergone significant transformations over time, influenced by historical contexts, societal attitudes, and advancements in healthcare systems. Understanding the historical evolution of these specialized fields is crucial for appreciating their current status and guiding future developments. This article delves into the historical perspective of gerontologic and geriatric nursing, exploring key milestones, influential figures, and significant developments both in the United Kingdom (UK) and globally. By examining the intersectionality of nursing for older adults with prevalent issues, this article aims to shed light on the multifaceted nature of caring for the elderly and its relevance to contemporary challenges.

Despite the fact that older people are disproportionately represented among those in need of healthcare, their treatment has historically received inadequate funding and recognition in the fields of medicine and nursing [1-4]. In general, nursing historians have not thought that older adult nursing is a subject that merits in-depth study.

Gerontologic nursing focuses on the care of older adults, emphasizing health promotion, disease prevention, and management of age-related conditions, while geriatric nursing specifically addresses the complex healthcare needs of elderly individuals. Understanding the historical context of these specialties is essential for appreciating their current status and future directions [5]. By delving into the historical context, this discussion elucidates the multifaceted nature of nursing for older adults and its intersectionality with prevalent issues such as falls [1-3,6-8] loneliness [4,9], nutrition and hydration [10,11] and the impact the ageing population have in moving and handling for the healthcare professionals [12-14], palliative care [15,16], etc. Through a comprehensive review of scholarly literature and primary sources, this paper highlights how historical perspectives can inform contemporary nursing practice and contribute to addressing the complex needs of older individuals. Additionally, it underscores the significance of adopting a holistic approach that integrates historical insights with current healthcare frameworks to enhance the quality of care provided to older populations.

The multidisciplinary study of ageing known as “gerontology” includes economics, society, psychology, and biology [17]. It seeks to comprehend the social and policy ramifications of growing older as well as the psychological, social, physical, and economic elements of ageing. Gerontologists work to enhance older individuals’ overall quality of life by addressing problems such as social isolation, loneliness [4], and lack of financial stability. They work together with experts in several domains to create comprehensive solutions for issues associated with ageing [17]. The field of geriatrics is dedicated to the medical treatment of elderly patients, including the diagnosis and treatment of age-related diseases, the management of chronic disorders, and the prescription of drugs specific to their requirements. It also aids in the maintenance of functional independence in older people by treating complicated medical conditions, mobility problems, and cognitive loss. Additionally, geriatricians seek to prevent age-related illnesses by immunization, lifestyle modifications, and regular health check-ups [5].

The evolution of gerontologic and geriatric nursing has been a multifaceted journey influenced by historical, societal, and healthcare factors. Throughout history, the care of older adults has transformed significantly to meet the unique needs of ageing populations. Notable advancements in the field include the establishment of specialized geriatric care units, progress in gerontologic research, and the incorporation of holistic approaches to elderly care [18]. Exploring the historical context of gerontologic and geriatric nursing allows nurses to develop a deeper understanding of the progression of their profession and the innovations in caring for older adults [19].

In ancient times, nursing played a vital role, with the earliest known nursing school dating back to 250 BC in India [20]. During ancient civilizations, the care of older adults relied heavily on familial and community structures, where caregiving was viewed as a moral duty [21]. Ancient Greek and Chinese societies placed great emphasis on respecting and caring for elders, highlighting the significance of familial responsibility in elder care [22]. In medieval Europe, care for the elderly was often provided by religious institutions, showcasing the role of monasteries and convents in delivering basic healthcare within a spiritual context [23].

The 19^th century witnessed a significant shift in elderly care provision, marked by the rise of formal healthcare institutions and the professionalization of nursing [24]. Influential figures like Florence Nightingale advocated for enhanced care for the elderly, stressing compassion, dignity, and holistic nursing practices [25]. Nightingale’s work laid the groundwork for modern nursing principles, emphasizing personalized care, environmental considerations, and evidence-based practice in caring for older adults [26]. The establishment of the National Health Service (NHS) in the UK in 1948 was a pivotal moment in healthcare, encompassing services for the elderly [27].

The mid-20^th century saw progress in gerontologic and geriatric nursing, with a focus on enhancing the quality of life for older adults [28]. Organizations such as the World Health Organization (WHO) began promoting age-friendly policies and practices to address the healthcare needs of aging populations [29]. In the UK, there was a push for active ageing and community-based care, reflecting a broader societal trend towards empowering and promoting independence in older adults [3,30]. The latter part of the 20th century saw an increased emphasis on holistic care, dignity, and autonomy in gerontologic and geriatric nursing, highlighting the importance of person-centered approaches in caring for older populations [15,16,31].

The 20^th century also saw the emergence of specialized training in gerontologic care and the professionalization of geriatric nursing [32]. Visionaries like Dame Cicely Saunders played a significant role in shaping geriatric nursing, particularly in palliative care [33,34]. The aftermath of World War II brought about substantial changes in healthcare, with governments investing in social welfare programs and healthcare infrastructure to support the elderly [35]. However, challenges such as recruiting nurses to work with older individuals, addressing stigma, and enhancing resources and facilities in care settings remain critical areas for exploration [36].

Geriatrics’ prehistory

An emaciated figure leaning on a staff represented “old” in Egyptian hieroglyphics from 2800 B.C.; this may have been the earliest illustration of the devastation caused by osteoporosis. The Ebers Papyrus (1550 B.C) proposed that cardiac purulency was the cause of senile degeneration [37]. Hippocrates thought heart failure and cardiac cachexia were the causes of old age, which was wet and cold, although Galen (10 AD) thought old age was cold and dry [37].

Cicero spoke extensively about ageing in De Senectute and discussed the anorexia syndrome in older adults. Franciscan monk Roger Bacon (c. 1214-1294) proposed that a restricted diet, relaxation, exercise, moderation in living, excellent cleanliness, and breathing in the breath of a young virgin might all prevent old age [37]. George Edward Day authored a practical book about ageing from the viewpoint of a physician, whereas Benjamin Rush penned pieces about the state of the body and mind in old age. The biblical account of King David sleeping with two virgins when he was old in order to regain his youth is most likely the source of this notion [37].

The papers “On the Condition of the Body and Mind in Old Age” and “Remarks on the Diseases of Old People” were published by Benjamin Rush in 1805. In 1848, George Edward Day (1815-1872) penned a treatise about ageing from the standpoint of a physician [37]. He bemoaned the lack of concern other doctors showed for the ailments of the elderly. Even in the early years of the twentyfirst century, this theme is still relevant. Many people consider Charcot’s “Clinical lectures on Senile and Chronic Diseases” to be a foundational work in the field of geriatrics. This has less to do with the text’s quality and more to do with the significance of Charcot [37].

The idea that ageing processes can be reversed by hormones started to take shape by the end of the 1800s. Victor Horsley believed in 1886 that thyroid deficiencies may lead to “mere senility” and that elderly people resembled myxedematous monkeys. Horsley was a neurosurgeon who performed the first transcranial pituitary approach and laminectomy for spinal malignancy. In addition, he was a key player in England’s rabies eradication [37].

When 70-year-old Brown-Sequard saw that he was becoming drowsy at night, he invented the first injections of testicular extract for rejuvenation. Victor DeLespinasse of the University of Chicago eventually performed human testicular transplants as a result of this. Due to the lack of people willing to give testicles for transplantation, Serge Voronoff invented “monkey-gland” transplants to revive the elderly wealthy. Brinkley attempted to transplant goat testicles in Kansas. These are the historical forerunners of the current andropause treatment with testosterone replacement therapy [37].

Early history: ancient civilizations to the middle ages

To comprehend the current landscape of nursing for older people in the UK, it is imperative to explore its historical roots.

We can trace the history of nursing back to ancient times, when it played a significant part in society. The earliest known nursing school to open its doors was in India in 250 BC, and it was exclusively for men [38]. In India, hospitals were established in communities from the third century BC. According to historical accounts, nurses had a critical role in staffing these and were expected to exhibit “good behaviour, distinguished for purity or cleanliness of habits.” In addition, they ought to be “skilled in every service that a patient may require, possessed of cleverness and skill, endued with kindness, attached to the person for whose service they are engaged” [38]. Nursing is also being associated with a higher need of emotional intelligence quotient and emotional awareness [39].

The care of older adults has roots in ancient civilizations, where familial and community structures played a central role. In ancient Greece, for instance, caring for the elderly was considered a moral obligation, with family members assuming primary responsibility [40]. Similarly, in ancient China, filial piety underscored the importance of respecting and caring for elders within the family unit [41].

During the Middle Ages in Europe, care for the elderly was often provided by religious institutions, such as monasteries and convents. These settings offered basic accommodations and rudimentary healthcare, albeit within a primarily spiritual framework [42,43]. Monks and nuns provided medical treatment for the sick. Certain religious groups constructed hospital wings where older and sicker patients might get better care and meals. Convents later began to provide nursing care [42]. In an effort to prevent vagrancy and potential lawlessness, the “poor” were kept off the streets by passing laws in Parliament in 1597 and 1601. The Poor Law system developed into a system that accommodated the needs of the sick, the chronically ill, orphans, and single-parent households in addition to the impoverished. Beginning in the 1630s, workhouses-later called poorhouses-became asylums for the elderly, sick, and mad by the end of the 1700s [42]. The conditions there were horrifying and quite severe. Poverty was once thought to be linked to a deterioration in moral principles.

Emergence of modern gerontologic and geriatric nursing

19^th century: Institutionalization and early advances: The evolution of nursing for older adults can be traced back to the establishment of formal healthcare institutions and the emergence of nursing as a profession in the 19th century. During this period, care for older individuals was often provided within almshouses or by family members, with limited professional intervention [44]. The 19th century witnessed significant societal shifts, including industrialization and urbanization, which disrupted traditional family structures and caregiving arrangements. Consequently, the elderly increasingly found themselves marginalized, leading to the establishment of almshouses and poorhouses to accommodate those without familial support [44]. People living in poor houses were therefore unjustly handled and judged [42]. To reduce public spending on poverty, the 1834 New Poor Law led to the construction of many additional poorhouses throughout the Victorian era. Individual parishes were in charge of their own needs until 1834. Following 1834, parishes were combined, and the largest workhouses, known as unions, numbered around 700. The Lancet’s editor advocated for upgrades in poorhouses. The workhouse wards were infamously referred to as “ante chambers of the grave” by a former editor [45]. Throughout his medical career, Joseph Rogers, a reformer of workhouses, provided guidance on the circumstances in Victorian workhouses [42]. “Workhouse medicine” failed the patients it served; there was no surgical room, no trained nursing staff, no casualty supply, and no medication. The prisoner’s circumstances progressively improved, and legislation was created to protect their welfare [42]. The Local Government Act of 1929 marked the end of the Poor Law. Nonetheless, a twotier hospital care system developed. Local government officials took over the management of the infirmaries that sprang out of the workhouses. Other hospitals were volunteer institutions with a superior social standing that favoured not admitting elderly patients. It was thought that elderly patients would not be as interested in learning and that they would clog beds. The earliest teaching hospitals were these volunteer hospitals [42]. Older patients were treated at hospitals that were once under the poor law, with little personnel and subpar amenities.

It was during this period that notable figures such as Florence Nightingale began advocating for improved care for the elderly. Nightingale’s work in nursing reform laid the groundwork for more systematic approaches to healthcare delivery, including the care of older adults [46]. Florence Nightingale, a seminal figure in the history of nursing, made significant contributions to the advancement of healthcare for individuals of all ages, including older adults. While Nightingale is perhaps best known for her work during the Crimean War and her pioneering efforts in modern nursing education, her influence extends to the care of older people as well [46]: a) Advocacy for dignity and compassion: Florence Nightingale advocated for the humane treatment of patients, regardless of their age or condition. Her emphasis on compassion, dignity, and holistic care laid the foundation for modern nursing principles, which are particularly relevant to the care of older adults. Nightingale recognized the importance of addressing the physical, psychological, and social needs of patients, emphasizing the significance of personalized care and empathy in nursing practice [46].
b) Environmental considerations: Nightingale’s environmental theory highlighted the impact of the physical environment on health outcomes. While her work initially focused on hospital sanitation and infection control, the principles of environmental modification have significant implications for nursing care for older people. Older adults are particularly vulnerable to environmental hazards such as falls, pressure injuries, and infections. By implementing Nightingale’s principles of environmental hygiene and safety, nurses can create conducive care environments that promote the well-being of older patients [46].
c) Holistic approach to care: Florence Nightingale advocated for a holistic approach to patient care, which encompassed not only physical health but also emotional, social, and spiritual well-being. This holistic perspective is especially relevant in the care of older people, who often present with complex health needs and multiple comorbidities. Nightingale’s emphasis on individualized care and therapeutic relationships underscores the importance of person-centered approaches in gerontological nursing practice. She made sure patients were stimulated mentally and emotionally. Nightingale created rooms where patients could learn something new from a teacher. She had these rooms set up to provide entertainment or let patients read books and keep their brains active [46].
d) Data-driven practice: Nightingale was a pioneer in the use of data and statistics to inform healthcare decision-making. Her meticulous record-keeping and data analysis during the Crimean War revolutionized public health practices and laid the groundwork for evidence-based nursing. In the context of nursing care for older people, Nightingale’s commitment to empirical observation and outcome measurement is invaluable. By collecting and analyzing data related to falls, medication management, nutritional status, and other key indicators, nurses can identify areas for improvement and tailor interventions to meet the unique needs of older patients [46].
e) Legacy of leadership: Florence Nightingale’s legacy as a leader and advocate for nursing continues to inspire generations of healthcare professionals. Her pioneering efforts in nursing education and healthcare reform have had a lasting impact on the profession, shaping the trajectory of nursing practice worldwide. In the context of nursing care for older people, Nightingale’s leadership serves as a guiding beacon, reminding nurses of their ethical responsibilities and commitment to excellence in patient care [46].

20^th century: professionalization and specialization: The early 20^th century saw the emergence of formalized nursing education and professionalization efforts. Nurses began to receive specialized training in gerontologic care, recognizing the unique needs of older adults. In the UK, pioneers such as Dame Cicely Saunders, known for her work in palliative care, contributed to shaping the field of geriatric nursing [34]. The aftermath of World War II brought about significant changes in healthcare, with governments investing in social welfare programs and healthcare infrastructure. In the UK, the establishment of the National Health Service (NHS) in 1948 marked a milestone in healthcare provision, including services for the elderly. When Britain’s National Health Service (NHS) was founded in 1948, municipal hospitals replaced poor law infirmaries as the primary facility for the treatment of the elderly. However, the amalgamation of all hospitals into a single service at the NHS’s establishment brought about enormous changes. Most chronic patients were housed in hospital structures that had been demolished by surveyors in the wake of World War II. Less than ten years after the NHS was established, in 1957, the government imposed a “geriatric bed norm” that resulted in an appallingly low number of beds per population of over 65s. Reducing elderly patients’ “burden” on hospitals was the overriding goal of chronic care services [42].

Historians have not given much thought to the evolution of older adult medicine in post-war Britain, although there is significant secondary literature on social care and “geriatric medicine” [47]. The most often referenced works are the edited collection Life, Death and the Elderly by Pelling et al. [48] and Means et al. [49], From Poor Law to Community Care: The Development of Welfare Services for Elderly People, 1939-1971. In the last few years, a number of publications on the development of “geriatric medicine” in the United Kingdom including Bridgen’s [50] study on hospitals and “geriatric” treatment from 1946 to 1976 have been published. However, Barton et al. [42] do note that there were significant advancements and an increase in the number of doctors interested in providing care for the elderly in the years after the NHS’s founding, particularly the 1947 founding of the Medical Society for the Care of the Elderly (later known as the British Geriatric Society). The British Medical Association is also commended by Means et al. [49] who claim that the organization “did not ignore this growing interest in geriatric medicine and the “chronic unwell”” (p. 119). Nevertheless, there were many more expressions of hope than anxiety, and noteworthy enough, Barton and Mulley are both doctors who treat senior citizens [47].

Two study papers by Doreen Norton, an innovative researcher and geriatric nurse, are included in the primary published literature. Hospitals of the Long-Stay Patient: A Study of their Practical Nursing Problems & Solutions [51] was the second book published in 1967, after An Investigation of Geriatric Nursing Problems in Hospital [52]. For this review, Norton’s concerns are especially pertinent. First, long-stay hospitals are inaccessible to employees, patients, and their families [51]. Seclusion and imprisonment from the outside world must inevitably result from people’s separation from their communities. Second, Norton highlights the “significant overabundance of inexperienced part-time employees compared to the quantity of full-time, skilled staff members.”

Late 20^th Century: Focus on Quality of Life: The latter half of the 20^th century witnessed a growing emphasis on improving the quality of life for older adults. This shift in focus led to advancements in gerontologic and geriatric nursing, with an increased emphasis on holistic care, dignity, and autonomy [1]. Internationally, organizations such as the World Health Organization (WHO) began addressing the healthcare needs of aging populations, advocating for age-friendly policies and practices [52-55]. In the UK, the promotion of active ageing and community-based care gained momentum, reflecting broader societal trends towards empowerment and independence for older adults [1-4].

The history of gerontologic and geriatric nursing is a testament to the evolving understanding of aging and the changing needs of older adults. From ancient caregiving traditions to modern healthcare systems, nurses have been at the forefront of providing compassionate and evidence-based care to older populations. The goal of this overview of geriatrics’ past is to give geriatric nurses working in the twenty-first century a solid basis. The previous fifty years are the centre of the epoch centric history, yet the field of geriatrics is just now beginning to grow. As we look to the future, it is essential to build upon the foundations laid by past generations, embracing innovation, collaboration, and a commitment to promoting health and well-being for older adults around the world.

In conclusion, the historical evolution of gerontologic and geriatric nursing underscores the importance of understanding the past to inform present-day practices and address the intricate needs of older individuals. By integrating historical insights with contemporary healthcare frameworks, nurses can adopt a holistic approach to improve the quality of care provided to aging populations. The ongoing evolution of gerontologic and geriatric nursing highlights the necessity of historical awareness in shaping future healthcare practices and ensuring that nursing care remains responsive to the evolving needs of society [18].

Florence Nightingale’s contributions to nursing care have profound implications for the care of older people in the UK and beyond. Her advocacy for dignity, compassion, and evidence-based practice laid the foundation for modern gerontological nursing principles. By embracing Nightingale’s holistic approach to care, environmental considerations, data-driven practice, and legacy of leadership, nurses can enhance the quality of care provided to older adults and promote their health and well-being [46]. Moreover, integrating historical perspectives into contemporary nursing practice fosters a deeper understanding of the challenges and opportunities inherent in caring for older populations, ensuring that nursing care remains responsive to the evolving needs of society [46].

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