Nursing and Caring: An Historical Overview from Ancient Greek Tradition to Modern Times

Abstract

Nursing as a humanistic profession is closely related to the core of caring which embraces the human essence in both illness and good health. This position paper examines the fundamental humanistic elements of caring and nursing particularly from a Greek perspective. to discuss critically the implications of care delivery mainly in Greece by looking at the deeper 'roots' of these notions, within their historical and geographical contexts. a historical literature search was undertaken in a 'time series snapshots' methodology whereby key events and historical contexts were critically appraised with regard to the evolution of nursing as an art and science. Both international and national library databases were used. Just like modern medicine, nursing also uses the Hippocratic Medical heritage as its base and therefore Hippocrates could be seen as a ' shared forefather' for health care professionals. It is often argued that in his early writings he described in detail what is now the nursing profession as he did not mention 'nurses' but referred to doctor assistants! Nursing has now become an independent scientific discipline with discrete evidence based knowledge but certainly the care side still has powerful historic, cultural and traditional roots. drawn from a review of the literature show that historically the roots of Nursing and Caring in Greece have a triple dimension. a) Caring care was provided within the family mainly by members, slaves and servants. b) Wartime nursing care was provided by private citizens but also by nobles who possessed the art of healing and caring. c) Organised nursing care was provided in many hospitals in the early Byzantine Empire. Hostels and Nursing Homes were run by monks and laity, voluntary men and women initially as a token of Christian love and later on payment.

Headnote

Abstract

Introduction: Nursing as a humanistic profession is closely related to the core of caring which embraces the human essence in both illness and good health. This position paper examines the fundamental humanistic elements of caring and nursing particularly from a Greek perspective.

Aim: to discuss critically the implications of care delivery mainly in Greece by looking at the deeper 'roots' of these notions, within their historical and geographical contexts.

Method: a historical literature search was undertaken in a 'time series snapshots' methodology whereby key events and historical contexts were critically appraised with regard to the evolution of nursing as an art and science. Both international and national library databases were used.

Results-Discussion: Just like modern medicine, nursing also uses the Hippocratic Medical heritage as its base and therefore Hippocrates could be seen as a ' shared forefather' for health care professionals. It is often argued that in his early writings he described in detail what is now the nursing profession as he did not mention 'nurses' but referred to doctor assistants! Nursing has now become an independent scientific discipline with discrete evidence based knowledge but certainly the care side still has powerful historic, cultural and traditional roots.

Conclusions drawn from a review of the literature show that historically the roots of Nursing and Caring in Greece have a triple dimension. a) Caring care was provided within the family mainly by members, slaves and servants. b) Wartime nursing care was provided by private citizens but also by nobles who possessed the art of healing and caring. c) Organised nursing care was provided in many hospitals in the early Byzantine Empire. Hostels and Nursing Homes were run by monks and laity, voluntary men and women initially as a token of Christian love and later on payment.

Key words: nursing, caring, ancient Greece, Rome, history.

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Introduction

There is an inherent difficulty in writing the history of nursing in the area of Greece because of the social context in which it has been practiced. Literature on this topic is scarce and diverse and further attempts to clarify this subject are needed in order to comprehend the current state of health care affairs.

Aim

The aim, of this position paper is to discuss critically the implications of care delivery in the Greece by closely reviewing the deeper 'roots' and pillars of nursing steming from ancient Greek caring practices, its core mission and values and the evolution of nursing within its historical and geographical contexts.

Method

For this paper's needs, a historical literature search was undertaken in a time series sequence whereby key events and historical contexts were critically appraised with regard to the evolution of nursing as an art and science for this specific geographical area. Key words used included: nursing, caring, ancient Greece, Rome and history in both Pubmed and Greek databases.

Results-Discussion

Providing nursing care in ancient Greece, a practice that could be argued continued until the mid 20th century, was mainly the work of women of every household. For this reason, the exercise of nursing activities in the ancient world could only be accessed through the social position of women throughout these periods.

In general, the dominant ideology at the time was that women should not have to deal with common matters or practice a profession. Under these conditions the social space where women could exercise nursing was confined to the site of the house which, however, was dominated by the ancient Greek proverbial philosophy: '...', which loosely translates to: 'house matters are not for the public eye' or in today's idiomatic phrase: 'don't wash your dirty linen in public'. The outcome of this social framework is that only limited and indirect references can be found in ancient texts concerning the exercise of nursing in ancient Greece and the Balkan area making it difficult to research and study (Sapountzi-Krepia, 2001).

The notion of 'nursing' is closely related to the essence of 'caring' as the philosophy which underpins the theory and practice of Nursing Science embraces the core human essence in both illness and good health. As Donahue (1985) points out, 'to care for' is not a phenomenon exclusive to nursing but it appears in various forms across all human constructs and civilizations throughout time.

Lachman (2012) defines care as

"...a commitment to attending to and becoming enthusiastically involved in the patient's needs". In these lines Morse et al., (1990) argue that: "If caring is to be retained as the "essence" of nursing, and if research in this area is to advance, then the various perspectives of caring must be clarified, the strengths and the limitations of these conceptualizations examined, and the applicability of caring as a concept and theory to the practice of nursing identified."

In a philosophical analysis of the concept of 'care', Marieskind (1998) stressed that the caregivers' incentives should be to remove or alleviate pain and discomfort of those they look after. The empathetic adoption of this attitude when caring comes when the caregiver develops the ability to imagine experientially the plight of others that is those who receive the care as if he were in his place.

Maclean and Theisen (2012) put care within an ethical framework, stressing that the provision of care is associated with a sense of morality and duty which are innate in many women, while one could also consider care to be directly related to technical aspects, educational preparedness, good interpersonal and communication skills and a moral sense towards the person who receives the care.

Women and care delivery: the beginning of Nursing?

Women's involvement in health issues is an ancient tradition in human cultures. Some evidence for this activity can be found in early historical texts. Undoubtedly there are even older unrecorded traditions but their roots are lost in the mists of time.

A large part of this historical heritage was lost as social changes confined woman to the 'loft', ousting women from exercising therapeutic interventions and the introduction of laws prohibiting women from formal education (Maclean 1974, Sapountzi-Krepia 1999, Sapountzi-Krepia 2013).

The word 'nurse' evolved from the Latin word 'nutrire' which means to nourish. The 'nourishing' aspect of nursing prevailed throughout centuries with the roots of nursing and medicine intertwined in ancient eastern and western cultures and religions. Still, it should be noted that even in the previous century, in much of the Balkans women were solely responsible for housekeeping and raising children. Limitations of their social role included not working outside the house and yet nursing was perceived as a 'female job'. In Turkish, the term 'nurse' means 'sister' i.e. hemsire kardes (Bahçecik & Alpar 2009). Similarly, the Greek equivalent to 'nurse' is '...' which again means 'sister'.

Thus, provision of nursing care was considered throughout the centuries as an internal affair of families and especially of women (Sapountzi-Krepia & Krepia 2005). In the long course as caregivers, women have sought and discovered the healing properties of herbs and other substances, which in the course of time spread by word of mouth, from one generation to the next (Laskaris, 2008). A report on the ancient knowledge from 3rd century BC regarding human milk dictates its use for treating burns alongside ear and eye infections, now proven to be effective due to its immunological and antimicrobial properties as described by Vorbach et al. (2006).

Nevertheless, nursing care provision is less often mentioned in historical texts although medical, religious and literary texts contain evidence of the contribution of women in treatment and care. The true and complete story of the contribution of women in health is sadly lost and even challenged in the writings of medical texts of literary women therapists especially when men were given credit for these writings (Achtenberg, 1990). As the boundaries of medicine and nursing were obscured for many centuries, healers, both women and men, practiced a mixture of what are now called Nursing and Medicine (Sapountzi-Krepia 2013).

The relevance of womanhood and its expression to what is now called 'care' regarding the Greek cultural heritage, can be traced back to the ancient Greek pantheon.

Nursing in ancient Greece

Evidence on the involvement of women with health issues can be found in Homeric works. Helen of Sparta learned the secrets of herbs via an apprenticeship in Egypt with Polydama, a renowned therapist and Queen of Egypt. According to Fernie (2006), borage was the famous nepenthe (medicine for sorrow, literally an anti-depressant) of Homer which Polydamas sent to Helen for a token:

"...of such rare virtue that when taken steep'd in wine, if wife and children, and mother, brother and sister, and all thy dearest friends should die before thy face, thou could'st not grieve, or shed a tear for them..."

In Homer's Iliad, Agamedes, daughter of King Aegeus, was claimed to know all the medicines on earth, and Hecamede, daughter of Arsinous, king of Tenedos, was credited for treating the wounded during the Trojan War (Morford et al., 2011).

Ancient Greeks worshiped Apollo the Sun God as the God of healing, while Asclepius, the son of Apollo, was the Greek God of medicine. Apollo's daughter Hygiea was the goddess of health and was credited for magical cures. In that era, much emphasis was given to personal cleanliness (hence the term hygiene), exercise and ortho-nutrition dietetics (Sapountzi-Krepia, 2004).

In some of the Hippocratic texts evidence can be traced for the role of women as exclusively providing therapy to other women, referred to "Omphaletómos - ..." (Umbilical cord cutting) and "latreousa - ..." (doctor-like tasks). Achterberg (1990) reports that according to Pliny (AD 50) Queen Artemisia of Ephesus could cure many diseases and gynecological conditions using special herbs.

The foundations of Greek Nursing can also be found in the sanitariums (...) of ancient Greece where some form of organized nursing was provided. Sanitariums pre-existed Asclepieia (...) which flourished in ancient Greece providing health care in a more structured form. It is reported that within their organizational structure there was a class known as 'zakoron- ...' or 'nakoron - ...' who cared for patients their duties being a mixture of servant and nurse (Risse, 1999; Lanara, 1993).

King (1998) argues that in ancient Greece and Rome there were special nurse- nannies who looked after children. In ancient Greece nursing care was the duty of women of the house, free or slaves. Historians have therefore concluded that nursing was the duty of Greek women and was considered at the time to be of little interest to the advancement of medical science (Basford & Slevin, 2003). It should be noted that the verb 'to treat' (...) in ancient Greek is to cure, hence the noun 'Therapainis - ...' (the maid or servant who provided care). Similarly, Thucydides (4th century BC) states that at the time of the plague in ancient Athens, patient care was provided by the women of the family, slaves and their friends (Tountas, 2012).

Xenophon (5th-4th century BC) in his 'Economics' mentions an Athenian citizen named 'Isomacho' who in instructing his young wife, said that within her house duties she was also to take care and supervise patients of slaves (Sapountzi-Krepia & Krepia 2005). The same author in his "Ascent Cyrus" says that in wartime there were outdoor military hospitals where nursing for the wounded was provided, while Plutarch in his biography of Solon also makes reference to hospitals for inpatient soldiers (Lanara, 1977; Messolora, 1959).

Roman period

The Roman civilization is well known for advances in public health. Ancient Rome had infrastructures like sophisticated sanitation, including sewage systems, drainage and public baths. During the early years of the spread of Christianity, many women and monks provided care for patients, primarily the elderly and the needy. The women were called 'Deaconesses'. These women were considered the predecessors of nursing because they used to tend to patients, the poor in their homes, prisoners and others by providing care for them. In this respect, the Deaconess Order may be regarded as the first 'visiting nurse' effort, since in apostolic times they cared for the sick poor in their homes as well as in hospitals. In the year 400 there were forty deaconesses serving as parish nurses in Constantinople (Blainey, (2011).

Phoebe, a disciple of the Apostle Paul, was the first-mentioned deaconess, alongside with Thekla, Nikareto and Theodosia. Phoebe in particular is regarded sometimes today as the first district nurse. Phoebe noted by her status as a deacon and 'Prostatis' one who should be esteemed highly because of her philanthropic work was trusted by Paul to deliver his letter to the Romans as his emissary to the church in Rome (Osiek, 2005).

A series of Roman women of high rank gave their wealth to charity and organized nursing groups also funding monasteries and hospitals. These important Roman matrons mainly of patrician family heavily influenced nursing by turning their immense energy and wealth to founding hospitals and raising the standards of nursing. These hospitals also practiced surgery as well as nursing (Ellis & Hartley, 2012).

In the early 4th century A.D. Fabiola, a Roman lady, erected a house for the care of the sick. She founded the first public hospital and later a hospice for strangers.

At the time, hospitals were mentioned as an established work and were spoken of with enthusiasm. Following her death, Fabiola was canonised.

Paula, another Roman noble, founded in Jerusalem a hospital and a religious community for women. Paula was a typical nurse of this period. She was an educated woman, and one historian goes so far as to pronounce her 'the first trained nurse' being one of the first who systematically trained nurses.

Marcella, another wealthy Roman, converted her luxurious home into a monastery. Her work mainly included praying and charitable tasks and was well renowned as an authority in biblical readings. She taught nursing as an art, rather than a service (Cilliers & Retief., 2002).

Women therapists continued this tradition actively, mainly towards women patients, up to medieval times. Therefore it can be argued that the spread of Christianity was a major milestone in the history of Nursing (Sapountzi-Krepia, 1999).

Early middle ages

Women therapists of all social classes were conveyors of knowledge of the medicinal properties of herbs and 'drug' preparation. They actively continued these traditions and applied knowledge in the care of sick women throughout the medieval period (Sapountzi-Krepia, 1999; Achterberg, 1990).

Until the thirteenth century A.D., despite the already established persecutions, women continued to work either as therapists or as caregivers. During the C13th A.D. it is estimated that in Europe approximately 200,000 nuns and commoners, provided organized care services under the auspices of the church (Nutting & Dock, 1907).

In northern Europe the medieval period brought plague and pestilence as people held an indifferent attitude towards sanitation and hygiene. Quarantine was adopted as a means to arrest the spread of such epidemics. Late in the 12th and 13th centuries nursing became differentiated from medicine and surgery as medicine went into a period of advancement while nursing remained limited to basic caring duties (Sweet, 2007).

Throughout Europe at the time, monks and nuns were dedicated to the alleviation of human suffering working as 'doctors and nurses'.

Although much of the ancient therapeutic wisdoms had been undermined through deliberate destruction, they were skilled in the use of home remedies. Their scientific knowledge in the care of the sick came from the books saved within certain monasteries, which in turn provided pre-foundations behind the development of universities (Silverman, 2002).

In the later middle ages, many social problems arose with further disintegration of the protective units like monasteries, guilds and feudalism resulting in the redistribution of the population.

Overall, the Dark Ages were haunted by superstition, mysticism, persecution of free thinkers and religious oppression. The therapeutic use of talismans and incantations for treating the sick predominated. Nursing declined in these dark times yet in the Balkan areas where the late Byzantine period prevailed the art of caring was preserved and continued to evolve.

Byzantine period

In Byzantium there were nursing homes for the elderlies, leprosarium, asylums for immediate post-natal care named "...", nurseries, orphanages and hostels that were the hospitals of that era.

These institutions employed paid staff and volunteers (nuns, monks and commoners) in order to provide care (Miller, 1997; Abel-Smith, 1982).

During the beginning of the 4th century in the early Byzantine era, the first hospital-type hostels began to operate as integral parts of the monasteries and by the 11th century, the renowned Pantocrator Xenon (hospital) Monastery was founded by the emperor John I Komnenos.

This was an exceptional example of a forerunner of today's modern hospitals as it had five wards for inpatients, including a surgical ward, women's ward, and an outpatient clinic. There were provisions for proper heating, lighting and bed linen, as well as bathing facilities and latrines. Care was supplied by a large and specialised staff of physicians, medical assistants and orderlies (Miller, 1997).

The hospital's daily operation is known in detail due to the survival of its founding charter, 'Typikon' which even dictates the pocket money allowed to patients.

The term "nurse" first appeared in 'Typikon' suggesting salaried officials of the hostel who were responsible for its operation. Their powers were similar to the authority of today's hospital directors. There is evidence in later texts that the term 'nurse' was synonymous with doctor, although the 'Typikon' leaves unanswered questions about the origin of the term (Kourkouta & Lanara, 1996).

Other health care workers mentioned in the 'Typikon' are 'Ypourgisses', female aids to doctors and 'Ministers' who provided a mixture of nursing services with servant orientated tasks.

Their main duties were: psychological support for the patients, routine care, comfort, cleaning and feeding, administration of medicines according to a doctor's instructions. Supervision in the absence of physicians was another task. Duties also included enemas, cuppings and bloodletting, which were the main therapeutic means at the time together with placing patients on the operating table and surgical assistance (Kourkouta, 1998).

Following the end of the Byzantine era, regarded by many scholars as the zenith of humanitarian generosity and kindness to the underprivileged, the rest of Europe was moving out the dark ages into the renaissance and later on to establishing the scientific foundations for nursing and care.

Renaissance period

During the Renaissance era, the first hospitals for poor patients began to be established in Europe undertaken by nuns and monks. Yet, despite the involvement of monks with care provision, the original roots of organized care and the nursing profession itself, being a caring profession, can be traced back to the servants of the houses, such as the slaves of ancient Greece and Rome (Abel-Smith, 1982; Delougery, 1977).

Gradually in the Renaissance Western World, hospitals were being established by municipalities and voluntary non-profit organizations. The staff who worked and provided care to the sick in these hospitals were poor illiterate women with their experience being only the upbringing of children and care of sick relatives (Abel-Smith, 1982).

Ottoman period

The Ottoman period that followed, although holds an abundance of war-time and conflict related nursing activities. Some historical references rescued refer to the actions of women during the siege of Thessaloniki by Ottoman troops in the 15th AD century (Dal & Kitis, 2008). Generally, in crises, many government and official buildings would be turned into makeshift hospitals where basic care services were provided despite insufficient facilities to meet this challenge.

Later, women from the nobility in Istanbul, participated voluntarily in the provision of healthcare services as they had been greatly influenced by the achievements of Florence Nightingale, who had demonstrated that good nursing care achieved a reduction of wound-related death rates from 42% to 2%. She had also demonstrated the therapeutic value of an affectionate and warm attitude toward patients (Bayik et al., 2002). This is a point not to be overlooked in today's technological nursing age.

Throughout the period of Ottoman rule, the Orthodox Christian monasteries were considered as asylums, due to the special privileges appointed to them. Therefore, these became the safest havens for the care of patients and injured fighters.

In Athens during this era (16th century), a well respected nun Philothei (1522 to 1589) known for her philanthropic activities and nursing care provision to patients founded a convent. She later inspired the founding of a monastery, hospital, nursing home, orphanage and seminary for women covering the needs of the Athenian population at the time and was recognized as a saint by the Orthodox Church for her humanitarian deeds (Botseas, 2010).

The dawn of modern nursing

From the mid 18th century, Europe saw the dawn of nursing. Florence Nightingale, the lady with the lamp during the Crimean war in 1854, is the symbolic figure of modern nursing, known for her devotion to serve the poor and sick and to raise the status of the nursing profession.

She became aware of the inadequate care being provided in hospitals, when she accompanied her mother on visits to the ill. What Nightingale saw in the hospitals intrigued her and made her want to become more involved. She decided to attend the nurse training program at Kaisersworth, Germany in 1850. Nightingale and a dedicated group of 38 untrained nurses went to the British hospitals at Scutari in Turkey were she found inadequate equipment and facilities. Her fist task was to organize and clean the hospital and provide improved care to the wounded soldiers. In 1860, she founded the first British training school for nurses at St. Thomas Hospital, London, 1860. Her services to the nursing science and profession were recognized through the honour of Order of Merit in 1907 (Retief & Cilliers., 2005).

The revival of scientific enquiry and learning in Europe during the 19th and 20th centuries affected nursing whereby the mid 1800's nursing became an organized practice. In the early 1900's, nursing education was received primarily from hospitals rather than colleges or universities. New nursing students were responsible for tasks similar to that of maids - dusting, scrubbing and doing dishes. These students typically worked 10 to 12 hour shifts, seven days a week, for a period of two to three years. Later responsibilities included sterilization of equipment such as needles and bandages and cleaning operating rooms. After graduating, most worked in patient homes as private-duty nurses and were paid amounts comparable to today's minimum wage. Their duties included bathing, administration of medications and enemas, and tending to wounds and sores (Cook, 2004; McCarthy-Haslam., 1998).

During this time period, hospitals evolved from facilities for the extremely poor and death-bound to institutions for general health treatment and childbirth. At the dawn of World War II, nurses were removed from their familiar hospital environment and placed at the bedsides of wounded soldiers, responsible for treatment decisions for the first time. To ensure adequate nursing staff for the duration of the war, the Cadet Nurse Corps program was initiated in 1943 to subsidize education for nursing students who agreed to work in the understaffed areas until the war's end. Well over 100,000 nurses received training through this program over the next three years. The nursing profession gained much recognition and support from civilians during this time, at long last realized as a tremendous asset to medical care (Winkelstein, 2009).

Despite the nursing and medical, scientific evolution and remarkable achievements of the last century, pockets of traditional healing and caring flourished in the Balkans. Kerewsky-Halpern (1985) in her long-term anthropological fieldwork in the Balkans describes the ritualistic healing roles of elder women in these largely patriarchal societies for the larger part of the last century, and can be found even to date. Folk pharmacology is perceived as being extraneous to the eventual cure which rests heavily on trust and touch as foundations of a healing and caring process. 'Patients' in this sense are essentially participants who have deep trust in the healer-Bajalica and faith in her words and touch which is the cornerstone of her treatment. The nursing ministrations of disinfection, application of balm and protective bandaging (the biomedical aspects) are viewed as coincidental to this healing process. Therefore, the fundamental efficacy of this elaborate healing ritual resides in culture elements embedded in a people's collective knowledge.

In rural Greece, in much of the previous century, customs, traditional preventive techniques, religious beliefs and superstitions were involved in health, sickness and prevention perceptions and behaviours. These views and customs were accepted by the local communities and hence gave psychological support to ill members. Along these lines, a young woman about to give birth, was convinced that a hand shaped dried herb was that of The Virgin and thus would help her during child birth (Tsiou, 2001).

By the late 1970s nurses realized that they should study and discover the deeper humanitarian roots of their profession, which make the foundation of the contemporary nursing profession and thus embarked on intensive efforts to uncover the trajectory of nursing from a humane ritual to a profession. Therefore, gradually, nurse researchers and scholars began to discuss the need to define and scientifically document what exactly 'care' and 'to care' means to nursing because care is a key element of Nursing. This included how 'care' manifests itself through nursing actions and whether and to what extent, caring should be the essence of modern nursing.

Yet, the concept of care in Greece today for example is somewhat compromised with very limited services for follow-up assistance in the home due to years of financial austerity affecting various branches of nursing and inadequate concern about the health of patients once outside the hospital setting (Kentikelenis et al., 2014).

Conclusions

The history of nursing care can be traced back to the beginning of human kind. For as long as there has been human life and interactions, there has been a constant need for care and comfort to fellow humans inflicted by injury or suffering from illness. The very roots of humankind required women to breastfeed and nurture the offspring preserving life and ensuring survival of the human race.

In this sense, nursing evolved from instinctive basic preservation acts to knowledge of how to care. In this respect, nursing has been called the oldest of the arts and the youngest of the professions.

Despite the glorious - and to an extent, glorified - past and great achievements in this geographical area, the contemporary Balkan Peninsula has been suffering from poverty and austerity. Recent financial hardships, predominatly in Greece today, put at risk the essence of care which can be often undermined where there is poor social or community nursing services and other health care resources.

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