The aims of this study are:
- To describe the bibliographical detail of the five editions of Instruccion de Enfermeros;
- To present a brief insight to the context of the text; and,
- To provide an overview of the key concepts of nursing care described in Instruccion de Enfermeros.
Method: The first stage of the analysis was performed by using historical method to describe the bibliographical details of the five editions of Instruccion de Enfermeros. The second stage of the analysis involved the identification of the key concepts described in Instruccion de Enfermeros. This was accomplished by performing inductive coding on an English translation of the second edition of the text.
Sources: Digitised copies of Instruccion de Enfermeros and an English translation of the second edition were used for analysis.
Results: Instruccion de Enfermeros had five editions published over more than a century. The information presented in Instruccion de Enfermeros is similar to the structural organisation of today’s fundamental nursing texts. The nursing interventions included in the treatise are organised under six pillars of instruction: medication administration, provision of hygienic cares, assisting with elimination, managing nutrition and fluid status, clinical skills and procedures, and other duties. Each nursing intervention is presented using a logical formula of Who, What, When, Where, How, Why and What if? The rationales for each descriptor of care are underpinned by anatomy and physiology, humoralism and clinical reasoning. Non-technical skills such as clinical judgement, communication, advocacy, prioritisation, problem-solving, reflection and critical thinking are also found in the descriptors.
Discussion: Instruccion de Enfermeros was written for a specific purpose: to instruct the Obregon nurses of Madrid General Hospital on how to provide better nursing care. However, the results of the analysis also reveal three main influences about why the text was required. These influences are: to address multiple organisational and external pressures, to improve clinical efficiency, and, to improve patient outcomes. The nursing profession will recognise many of the issues that this text was attempting to address as being reflective today.
Recommendations, Implications and Limitations: This analysis revealed that there were a number of amendments in the final edition of Instruccion de Enfermeros. The fifth edition was published 103 years after the second edition, therefore, it would be beneficial to analyse and compare its content to the first and second editions to assess how nursing care evolved over this period.
This study found that numerous elements of contemporary nursing practice were described in Instruccion de Enfermeros. The inclusion of such elements in Instruccion de Enfermeros intimates that core aspects of nursing’s identity and clinical practice evolved through the transgenerational sharing of knowledge. Its discovery also suggests that other nursing texts were written prior to Nightingale’s (1859) Notes on Nursing – What It Is and What It Is Not. However, as a profession we know little about the influence of such manuscripts prior to Notes on Nursing, and how, or if, they helped shape contemporary nursing practice and identity. To address this paucity of knowledge, a larger study is needed to identify and examine texts on foundational nursing care that were written prior to Nightingale’s work.
Conclusion: Instruccion de Enfermeros provides an insight to the role of the nurse during the seventeenth century. The manuscript has a structure that is similar to contemporary fundamental nursing texts and includes a step-by-step guide for performing a range of key nursing procedures. The text underwent rigorous peer-review and was underpinned by (then contemporary) scientific and/or clinical reasoning. The first and second editions’ prefaces, intentions and rationales suggest seventeenth-century Spanish nurses experienced external and organisational pressures that are similar to today’s workforce. To address such pressures, they needed to develop an informed knowledge base, be technically proficient and possess a range of non-technical skills. Instruccion de Enfermeros therefore challenges our profession’s assumptions about historical nursing practice.
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