Military Nursing History
U.S. nurses (mostly males in the first century-and-a-half) have aided sick and wounded warfighters on the battlefield since the Revolutionary War – although not officially part of the military until the 20th century.
The Continental Congress, at the request of Gen. George Washington, on July 27, 1775, approved hiring one nurse for every 10 patients in Army hospitals at a pay of $2 per month, $4 for nurse supervisors. The pay per nurse was raised to $4 when the Revolutionary War began a year later and their duties increased with combat casualties. In addition to the care they gave the soldiers, having a female nurse replace a male freed that man to join the fight.
Those first nurses were untrained and many the wives of soldiers, who had no way to support themselves and had begun following the Army, doing odd jobs, for food and lodging.
When the war ended, female nurses were dismissed. Despite fighting two more wars – the War of 1812 and the Mexican-American War (1846-1848) – female nurses were not employed by the Army again until the Civil War. Still working with no training, more than 6,000 served in both Union and Confederate hospitals and closer to the battle lines. A major step forward was made on June 10, 1861, when the Union named Dorothea Lynde Dix “superintendent of women nurses,” creating the first organized unit of U.S. nurses. As with the Revolution, however, they were civilian hires, not members of the military in either army.
As before, the end of that war meant the end of the Army’s perceived need for such support, returning instead to only a small cadre of male nurses. Female nurses were not employed again until the Spanish-American War (1898), when the first contract hires were made to deal primarily with outbreaks of yellow fever, malaria, and other tropical diseases. Although that conflict only lasted four months, 21 of the more than 1,500 nurses who served died, largely from tropical diseases contracted from their patients.
Once again, most of the women who applied were untrained, and the War Department had no resources to see if they were medically qualified. The Daughters of the American Revolution offered to serve as an examining board for potential nurses and, for the first time, an acceptable applicant had to have graduated from a training school and provide suitable recommendations.
Recognizing the value nurses provided – and the need for more than the few male nurses the Army normally employed – the U.S. surgeon general laid out the criteria for a reserve force of nurses in 1899. Two years later, Congress made nurses a full part of the military by creating the Army Nurse Corps (ANC). The Navy Nurse Corps was established seven years later.
The Army Reorganization Act of 1901 also created the first Reserve Corps of female nurses, most of whom previously had served at least six months in the Army.
For the first time, the U.S. military had an organic corps of military nurses, trained to work close to the battle lines, which proved vital when America entered World War I in 1917. Although there were only 403 Army and 160 Navy nurses on duty at the time, by the end of the war in 1918, more than 22,000 had served, several decorated for their actions, including the Distinguished Service Cross and Medal of Honor. Several hundred of those also died in service, many victims of the 1918 Spanish Flu epidemic, according to the American Society of Registered Nurses®.
World War I also saw the creation of the Army School of Nursing, which began courses specific to Army nursing at several military hospitals in 1918.
After World War I, the military realized there was a problem with medics and others too often ignoring the authority of nurses because they were not commissioned. As a result, in 1920, military nurses were assigned “relative ranks” as lieutenants, captains, and majors, although the surgeon general ordered that they be addressed as “Miss” rather than by their ranks. Their pay was half that of male officers of the same rank, but the support of line generals and nursing organizations led to legislative changes in status and retirement.
By the 1930s, military nurses, for the first time, were given full pay and allowances while attending advanced educational courses, especially in anesthesia and psychiatry, at universities across the nation. Those post-graduate courses served them and the military well in the conflict to come.
Nurses became a significant part of the military after the United States entered World War II in December 1941, facing combat across the globe against the two strongest militaries of the time: Nazi Germany in Europe, Africa, and western Asia, and Imperial Japan in the Asia Pacific. The American National Red Cross issued an urgent appeal for 50,000 nurses to join the Army and Navy nurse corps.
In a 1942 editorial in the American Journal of Nursing, first lady Eleanor Roosevelt added her plea for women to join. Citing her four military sons, she wrote:
I ask for my boys what every mother has the right to ask – that they be given full and adequate nursing care should the time come when they need it. Only you nurses who have not yet volunteered can give it. … You must not forget that you have it in your power to bring back some who otherwise surely will not return.
Overall, more than 70,000 nurses joined the two corps, dozens of whom became Japanese prisoners of war, and many others who were trapped behind enemy lines in the middle of combat on both sides of the world. Their actions led to the lowest death-after-wounding rate in the history of war, with fewer than 4 percent of warfighters treated by nurses in the field dying from wounds or disease.
It was not until 1947 that Army and Navy nurses were granted true permanent commissioned officer status, giving them the full rights, privileges, authority, and pay to which their ranks entitled them.
As depicted in the TV show M*A*S*H* (Mobile Army Surgical Hospital), Army nurses served close to the front lines during the Korean War (1950-53) – the only women allowed in the combat zone. They also were present in field hospitals and on Army transport ships and hospital trains. Air Force nurses served in Japan and as flight nurses in the Korean theater. Navy nurses served on hospital ships in theater, the first time women were assigned to Military Sea Transportation Service ships. Several nurses from all services died during the war, most in plane crashes en route to Korea. As that war drew to a close, the first woman physician was commissioned in the Army.
That conflict also saw the first woman enter the Air National Guard – Capt. Norma Parsons – who served as a nurse in the China-Burma-India theater.
The Vietnam War (1965-72) saw a bit of a reversal in history as the first male nurses served in that war, their first major deployment since having been allowed into the Army and Air Force nurse corps and the Army Medical Specialist Corps in 1955 (it would be another 10 years before they were accepted into the Navy Nurse Corps). Male Army nurses were sent into areas considered too dangerous for female nurses, but Vietnam was America’s first war without clearly defined fronts, placing all nurses in the greatest danger in military nursing history and leading to a number of deaths and wounded among the thousands who served in theater.
The ratio of male-to-female nurses changed significantly in the latter half of the 20th century, according to Col. Michael Ludwig, chief nursing officer at Brooke Army Medical Center, in San Antonio, Texas: “There are more male nurses in the Army than in the civilian world, although there are more women than men in military nursing.”
Vietnam also saw a number of changes for the ANC, including the removal of all restrictions on the careers of female officers in 1967. As a result, in 1970, the chief of the Army Nurse Corps and the Women’s Army Corps director became the first women promoted to brigadier general. In 1971, the first woman was assigned as a flight surgeon in the Air Force and the Air Force Reserve. In 1972, the hospital ship USS Sanctuary became the first naval vessel to sail with a male/female crew, and the Navy promoted the director of the Navy Nurse Corps to that service’s first female rear admiral.
In 1979, an Army Nurse Corps officer became the first black female brigadier general in the history of the U.S. military.
The first Air Force Reserve nurse was promoted to brigadier general in 1985.
Military nurses were deployed to the brief first Gulf War (1991), but served in the largest numbers since Korea during the second Gulf War (2001- ), the longest sustained armed conflict in U.S. history. They helped contribute to the lowest U.S. killed-in-action rate in the history of warfare in both Iraq and Afghanistan, where, due to the asymmetrical nature of that war, they once again were subject to hostile fire. They also frequently found themselves treating more locals – including enemy soldiers – than U.S. or coalition casualties.
The Muslim culture, especially in Saudi Arabia during Operation Desert Storm and later in Afghanistan, was at times, difficult for American female nurses, who worked in their regular uniforms alongside men, some under their command, which was alien to the local males, who sometimes criticized their dress and actions. But a 2008 study by the Brigham Young University College of Nursing found a common theme among the nurses who served – and continue to serve – in Southwest Asia: “We did what we had to do. It’s what we’re here for.”
Today, Army, Navy, and Air Force nurses of all ranks and specialties serve around the world, in permanent U.S. military hospitals in the States and overseas, such as the Landstuhl Regional Medical Center in Germany, the largest U.S. military hospital outside the country; aboard Navy hospital ships and Air Force medical transport aircraft; and deployed to both combat zones and natural disaster aid sites.
In their nearly 250 years of service, from the untrained women hired for $2 a month by the Continental Army to today’s highly trained commissioned officers, military nurses – especially female – have made unprecedented progress and saved untold numbers of soldiers, sailors, airmen, and Marines in nearly every war the nation has fought, as well as peacetime duty caring for the sick and injured.
VA Nursing History
The foundation of today’s VA Nursing Service took shape in 1930, when three federal agencies responsible for veterans’ programs consolidated into the new Veterans Administration (VA). Approximately 2,500 registered nurses who had been assigned to the U.S. Civil Service went to work for the new VA. Although classified as “sub-professional” at the time, graduation from a state-approved school of nursing was required for VA employment, according to Alan Bernstein, deputy chief of the VA’s Nursing Office.
The history of providing care for America’s veterans, however, stretches back to early colonial times. In 1636, a law passed by the Pilgrims of Plymouth Colony stated that disabled soldiers – primarily from the war with the Pequot Indians – would be supported by the colony.
In 1776, the Continental Congress sought to improve enlistments during the Revolutionary War by providing pensions to disabled soldiers. For the first three decades following the Revolution, individual states and communities provided direct medical and hospital care to veterans. It wasn’t until 1811, just prior to the second war against the British, that the federal government established the first home and medical facility for veterans. Later in the 19th century, veterans’ assistance programs were expanded to include widows and dependents.
The Veterans Health Administration (VHA) traces its history back to the closing days of the Civil War, when President Abraham Lincoln signed a law establishing a national soldiers and sailors asylum for that war’s veterans, the nation’s first federal soldiers’ facility. The first of the new national homes – aka soldiers’ homes or military homes – opened in August 1866 near Augusta, Maine. They were restricted to Union Army veterans, including U.S. black troops. By 1929, there were 11 of those homes across the nation, accepting veterans of all wars.
A number of veterans’ homes that included medical and hospital treatment also was established by the individual states following the Civil War. Those homes provided such care to indigent and disabled veterans of the Civil War, Indian wars, Spanish-American War, and Mexican border skirmishes, along with discharged regular members of the armed forces.
“Men were the primary nurses at our earliest facilities – the National Home for Disabled Volunteer Soldiers – until 1890, when the first women nurses were hired,” according to the VA historian. “They were called stewards at the time. Overall, nursing was a male-dominated field in the U.S. until after the Civil War.”
With America’s entry into World War I, the federal government established a new system of benefits for veterans, including vocational rehabilitation. After the war, administration of benefits to veterans was handled by three separate federal agencies: the Veterans Bureau, the Bureau of Pensions of the Interior Department, and the National Home for Disabled Volunteer Soldiers (NHDVS).
Hundreds of private hospitals and hotels were leased by the Bureau of War Risk Insurance and the Public Health Service in 1918, creating the second-largest VA hospital system, specifically to deal with returning World War I veterans. They also began building new dedicated veterans hospitals.
The Veterans Bureau was created in August 1921 to bring all World War I veterans programs under a single agency. Veterans hospitals run by the Public Health Service were transferred to the bureau in 1922, along with 1,400 nurses, and construction began on a number of new hospitals for veterans across the nation. In 1928, admission to NHDVS homes was extended to women, National Guard, and militia veterans. A majority of today’s VA hospitals and medical centers came from the facilities operated by the three agencies.
The Veterans Administration was created on July 21, 1930, by elevating the Veterans Bureau to a federal administration and merging the National Homes and Pension Bureau into the new VA. Approximately 2,500 registered nurses were employed in the new VA Nursing Service. In 1946, the VA’s Department of Medicine and Surgery was created, later re-designated as the Veterans Health Services and Research Administration. That became the VHA in 1991.
“Public Law 293 [Title 38 U.S.C.] was passed in 1946 to reorganize and modernize the VA health-care system. It removed VA nurses, physicians and dentists from Civil Service, placing them in their own ‘Title 38’ personnel system under unique and specific personnel policies. Under this system, VA nurses were compensated according to experience, education and competencies, regardless of position assignments [i.e., clinical or administrative],” according to information Bernstein provided for this publication.
“The first VA nurses mainly came from the armed forces. However, after local and regional experience with recruitment advertising during the late 1980s, VA launched its first national nurse recruitment advertising campaign in February 1990. Today, most VA nurses come from the civilian sector and students from accredited schools of nursing.”
Since World War II, VA nurses, many of whom are reservists, have been called into active service to provide care for warfighters in combat zones and military hospitals. The demand for such nurses during World War II and the Korean War caused nursing shortages at VA hospitals back home. That service continues today, with many VA nurses having been deployed with their Reserve units to Iraq and Afghanistan.
Today, the VHA has become one of the largest health care systems in the world, providing training for a majority of the nation’s medical, nursing, and allied health professionals. According to the VA’s history website, some 60 percent of all medical residents receive at least part of their training at a VA hospital. The VA operates 1,600 health care facilities, including 144 VA Medical Centers and 1,232 outpatient sites, up from only 54 hospitals in 1930.
The VHA’s medical facilities have expanded to cover a wide range of veteran conditions, including traumatic brain injuries, post-traumatic stress, suicide prevention, and more, as well as establishing telemedicine and other services to accommodate today’s diverse veteran population and incorporate the latest technologies.
“The number of nurses employed by VA has increased with the increase in number of veterans seeking care at VA facilities,“ Bernstein said. “In 1921, about 1,400 hospital nurses from the Public Health Service were transferred to the new Veterans’ Bureau, the forerunner of VA. In 1930, when three federal agencies responsible for veterans’ programs consolidated into the new Veterans Administration, approximately 2,500 registered nurses then assigned to the U.S. Civil Service went to work for VA. As of January 2019, the VA employs over 100,000 total nursing staff members.”
Bernstein said that number includes 71,286 RNs (15 percent of whom are military veterans), 15,001 LPNs (18 percent veterans), 13,234 nursing assistants (14 percent veterans), and 1,023 nurse anesthetists (28 percent veterans).
“Taken together as a combined population, approximately 19 percent of VA nurses are veterans,” noted Karen Ott, the VA’s director for Policy and Legislation.
Since the 1960s, advances in medicine have required specialized training programs and expanded the need for advanced practice nurses (e.g., nurse practitioners and clinical nurse specialists) in a number of areas. Education and research thus became increasingly integral components of the VA Nursing Service.
Today, VA nursing has become the largest clinical training and cooperative education system, working with undergraduate and graduate programs at numerous colleges and universities. Several people within the VNS estimate 1 out of every 4 professional nursing students in the country receives some training from the VA.
In addition to clinical care, VA nurses also are heavily involved in advancing medical research and helping the VHA keep up with the latest technological innovations. Nurse researchers help promote inclusion of evidence into practice to provide quality care for veterans. The VA nurse corps also plays a significant role in VA emergency planning, preparedness, response, and recovery.
The types of care VA nurses are required to provide veterans began to change significantly in the 1960s, as the Vietnam War saw more and more veterans seeking help with a variety of ailments. Greater efficiencies in evacuating wounded warfighters from the battlefield and providing immediate care led to a dramatic increase in survival rates and, subsequently, in the number of disabled veterans seeking care from the VA.
New diagnostic techniques led to other changes resulting from the wars in Southeast – and later Southwest – Asia, with new types of poly-trauma injuries requiring specialized expertise. Longer life expectancies also increased the need for geriatric and long-term care for veterans of earlier conflicts. By the 1970s, nurse practitioners had become the primary providers of VA patient care and the use of clinical nurse specialists was expanded.
In the 21st century, VA nurses are constantly training and involved in continuing education to ensure state-of-the-art care to more than 9 million veterans, ranging from the last survivors of World War II to those who recently left active service. That covers a wide range of services, comprising not only patient care but also clinical practice, education, research, and administration. In addition to medical, surgical, and psychiatric units, VA nurses work in intensive care, spinal cord injury, geriatric, dialysis, blind rehabilitation, specialty care (e.g., diabetes clinics) and hospice, domiciliary, oncology, and organ transplant units, providing primary, ambulatory, acute, rehabilitative, and extended care.
“We see nurses continuing to be the largest group of care providers in the VA system, with expanded scopes of practice for all nurses and full practice authority for the advanced nurse practitioners. In addition, we see continued growth in care in the community and virtual health care,” Bernstein said.
This article originally appears in the Veterans Affairs & Military Medicine Outlook 2019 Spring Edition