1. Virginia Henderson Lecture
Dr Edward Halloran, RN, MPH, PhD delivers the Virginia Henderson
Lecture at the 24th
ICN Quadrennial Congress in Durban, South Africa.
Women hold up half the sky
Edward J. Halloran, RN, MPH, PhD delivered the Fourth Virginia Henderson
Lecture at the 24th
ICN Quadrennial Congress on 1 July 2009 in Durban, South
Africa. The lecture honours Virginia Henderson, an American nurse who made an
extraordinary contribution to nursing and health. Like Florence Nightingale, she
moved nursing forward as a respected profession based on the science and art of
caring. Dr Halloran is a scholar of Henderson’s writings and their implications for
public policy. Following is an excerpt from the lecture.inr_781 410..415
The English word nurse is used synonymously with the word
woman. Most nurses are women and where pronouns are used in
the singular, the nurse is invariably referred to as she. This may
seem natural to many of you but to me it does not. I am from a
very unique situation in both time and place. Ours was a time of
enormous privilege for men. Education, pay, position and
opportunity were all disproportionately given to men, even when
the work was performed by women. Hospitals, the locus of
health care in America, were and are dominated by elite men.
After 35 years of study of patients, their nurses, and the agen-
cies we work for – I have come to believe that men have failed us.
Women offer us all hope for a better future. For centuries women
of the world have been denied substantive education, except for
nurses. The education has been meager and reluctantly given, but
nonetheless, it places nurses in a unique position. If women are
to lead, nurses, by reason of their education, must lead women.
The thread that holds this essay together is the tension or
structured conflict between men and women that exists in health
care around the world (Rosenberg 2007). This conflict was to
some extent considered by Nightingale (1863), and she described
it best in her appendix to Notes on Hospitals, 3rd
edition. She said
the best interests of the sick were served by a perpetual rub
between nurses and doctors and between hospital administrators
and nurses.This disagreeable collision keeps all belligerent parties
to their duties and reflects beneficially on the interests of the sick.
She added that the threat of publicity is the best guardian of the
interests of the sick. Her remarks are a far cry from the collabora-
tion and cooperation that many seek from nurses. Four areas,
prevention versus cure, modern nursing versus medicine, human
needs versus disease classes, and the International Council of
Nurses (ICN) versus the World Health Organization (WHO),
deserve further scrutiny here. I hope this publicity will serve the
interests of both the sick and the well (Henderson 1960).
Prevention versus cure
Our health care challenges throughout the world will not be
managed by medical science alone (Rosenberg 2007). One need
only look at the HIV-AIDS pandemic to see the cost in human
misery of waiting for a cure. Dr Sheila Tlou, ICN’s second Vir-
ginia Henderson lecturer, writes of her frustration with medicine
and men when Botswana’s citizens suffered while waiting for
science to stop the disease. (Tlou 1996, 2001) Dr Tlou knew then
and knows now that prevention stops HIV-AIDS. She knew, too,
ICN
© 2009 The Author. Journal compilation © 2009 International Council of Nurses 410

2. that if the disease were to be prevented, nurses would have to play
an enormous role (Tlou 2001a). In the words of Virginia Hend-
erson, the nurses would help people, sick or well, perform activi-
ties contributing to health where individuals lack strength, will,
or knowledge. We should have brought – we should still bring –
our army of nurses and women to bear, specifically with our
interventions, encouragement and education. The HIV-AIDS
scourge can conceivably be eradicated through prevention in a
generation. Who needs a cure when disease can be prevented?
Florence Nightingale faced the same obstacles from men of
science during her active career. As a sanitarian she observed and
participated in sanitary improvements on the health of soldiers
and measured the effect of these improvements on the British
Army. Her most important writing concerned the protection of
the British Army from preventable disease (Nightingale 1858).
In America, after Harriet Martineau (1859) published a book
based on Nightingale’s Notes on the British Army, ladies of the
Women’s Central Association for Relief formed the United States
Sanitary Commission (Halloran 2002). This voluntary agency
used Nightingale’s sanitary science, along with an inspection
form she developed for India, to teach Union officers in the
Northern Army to prevent disease (Stille 1866). The disease mor-
tality the Union Army experienced was one fourth of what the
British Army had encountered less than a decade before. During
this remarkable period of writing and reform, Nightingale
(1860) prepared her most famous document, Notes on Nursing.
This work has much more to do with prevention than with relief.
In the ensuing decades most nursing has stressed relief. Night-
ingale believed that less relief is needed if illness is prevented.
Modern nursing versus medicine
Virginia Henderson knew that the antibiotic changed medicine
and nursing. She noted the need to reformulate nursing and
distinguish the nurse’s role from the physician’s. At the end of
the Nightingale era, in 1950, Henderson took up the cause. She
spent five years completely revising a textbook, Harmer and
Henderson’s Textbook of the Principles and Practice of Nursing,
5th
edition.
How was nursing perceived when Henderson began her revi-
sion? Mostly, nurses were the performers of skilled procedures
learned in apprenticeship training on hospital wards. Hender-
son’s genius not only extended the emphasis on nurses’ perfor-
mance of skills but now contextualized them. Nurses learn to
perform procedures for patients but do so only when individuals
lack the strength, will or knowledge to perform the tasks them-
selves; even then, they do so only until individuals gain strength.
Henderson’s emphasis on rehabilitation and the independence
of patients from nurses was one major difference between the 5th
and previous editions of her textbook. Virginia Henderson vir-
tually redefined modern nursing yet maintained continuity with
the past.
We have begun to measure the effect of encouragement and
support in randomized controlled clinical trials with some inter-
esting results. Two research teams have more recently used Hend-
erson’s formulation as a jumping-off point for more detailed
studies. Dorothy Brooten et al. (1986) and Mary Naylor et al.
(1999) have published reports of interventions used by nurses to
support and educate patients and their families. Their findings
are consistent even among such diverse populations as prema-
ture infants (and their parent[s]) and old sick people with heart
disease. Individuals and their families do better with support and
education from visiting nurses than do those who receive more
hospitalization, more physician visits and more long term
care institutionalization. David Olds et al. (1997) and Harriet
Kitzman et al. (1997) and their colleagues are revolutionizing the
prenatal, infancy and early childhood experience of first time
mothers with home visits by nurses who give encouragement,
support and education. Research reports describe families receiv-
ing intervention from nurses as being better off according to a
number of social measures than are those not provided the
service. The Nurse-Family Partnership Program has now been
adopted for use in a wide variety of American states and counties
(Boo 2006). Both of these investigative teams have been implic-
itly testing Henderson’s theory that support and education
reduce dependence. Both teams have prevented problems from
developing – problems that have caused control group members
to suffer in comparison.
Over her very long and active professional life, Virginia Hend-
erson had many opportunities to reflect on her theory and her
writing, and she chose not to change the description of nursing
she authored for ICN (Henderson 1991). As a textbook author,
she relied on writers who were both scientists and clinicians and
who used peer review practices to prepare our professional lit-
erature. Henderson uniquely knew this literature as she had
indexed all the papers by nurses and about nursing written in
English from 1900 to 1975 and used her vast intellectual powers
for synthesis (Henderson 1963, 1966, 1970, 1972). Henderson
read all that was written about nursing in English and organized
the material so that it could be taught and learned. Of note here
is the enormous amount of professional literature she reviewed.
The clinical papers and research reports were written mostly by
women who had been deprived of education on anywhere near
parity with men. We should all celebrate the depth, scope and
richness of our literature, accumulated against all odds for well
over a century after Nightingale’s informed reports.
The knowledge made available to us in our professional litera-
ture and her synthesis is what enables nurses to offer a desirable
Virginia Henderson Lecture 411
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3. service to patients, with or without doctors, in hospital or not.
Nurses must have parity with physicians in accessing and helping
people become more independent in activities contributing to
health, its recovery, or to a peaceful death. Physicians, too, want
independence for patients but use medicines and surgery to
achieve it whereas nurses use strength, encouragement and
support, and teaching to achieve independence. I agree with the
British Medical Association, which recommended that patients
see nurses before they see doctors (BMJ News Roundup 2002).
Human needs versus disease classes
Needed now is a system for classifying patients to take advantage
of developments in digital communication. Bethina A. Bennett
was principal nursing officer for the Ministry of Labor and
National Service in Winston Churchill’s post-war English gov-
ernment. Responsible for nursing manpower issues in a country
that had just adopted the National Health Service, Bennett was
required to describe who nurses were and why they were needed.
She found her answers in Henderson’s 1955 textbook and advo-
cated in Nursing Mirror that British nurses read, understand and
consult this ‘most stimulating’ book (Bennett 1956).
Bennett went further. As chairwoman of the ICN Nursing
Service Committee, she commissioned Henderson to write Basic
Principles of Nursing Care. The first draft of this significant docu-
ment appeared in a seven-part series for the 1958 Nursing Mirror.
ICN refined this draft through a feedback process and published
it in 1960, 100 years after the appearance of Nightingale’s Notes
on Nursing. The importance of this intellectual endeavor, coming
on the heels of the widespread use of the antibiotic and the
development of the National Health Service, cannot be
overstated.
Henderson expanded her description of nursing by adding
14 fundamental human needs: breathing, eating and drinking,
eliminating, moving, sleeping, dressing, maintaining tempera-
ture, keeping clean, avoiding danger, communicating, worship-
ing, working, playing, and learning. ICN’s Basic Principles of
Nursing Care comprised the depiction of these human needs and
the nurses’ activities in helping individuals meet them, especially
when modified by conditions like age, temperament, social and
cultural status, and physiological and intellectual capacity, as well
as by pathological states.
ICN’s Basic Principles of Nursing Care was a sensation, was
translated by ICN member states into 30 of their languages, and
helped standardize the nature of nursing. Henderson, too, went
further and wrote a new edition of her textbook, a job she under-
took in her 73rd
year. Published in 1978 when she was 81 years of
age, the 6th
edition of Principles and Practice of Nursing was
written around the fourteen-human-needs she had detailed for
the ICN. John D. Thompson, RN, my teacher and a Yale nurse,
introduced me to Virginia Henderson in 1975. Thompson was
known principally as the finder of diagnosis related groups or
DRGs, which are used now for budgeting hospitals and health
services (White 2003). Henderson was writing the 6th
edition of
Principles and Practice of Nursing without reference to disease at
the same time Thompson was creating the DRG system based on
disease diagnosis and treatment (Henderson & Nite 1978).
Together, these two great Yale nurses created in me a schizophre-
nia from which I am only now recovering.
Using Thompson’s logic, all institutional nursing flowed from
disease specificity – when the disease was known and the treat-
ment started, and DRG assigned, the nursing care (and payment
for it) was standardized. Henderson thought differently. To her,
human needs were fundamental, and needs were always affected
by social and developmental factors and sometimes modified by
pathological states. These differences in perspectives are no small
matter. In some countries nurses do what they are told by phy-
sicians, whereas in others nurses see patients independently of
doctors and hospitals. Then, as now, it is imperative to describe
both what nurses do (their unique function) and how much time
it takes the qualified nurse to perform in a predictable way to
help people with specific needs become independent in their
performance.
My own quantitative research addressed both the time spent
by nurses with patients and the time patients spent in hospital
(Halloran et al. 1988). In both cases, variations in time were
better explained by nursing need than by DRG. The results led
me to conclude that if patients are admitted to hospital by phy-
sicians, nurses should discharge them. I also found further evi-
dence that universal human need triumphed disease. When
people neared death they acted more alike than as members of
their respective disease groups. Nurses, too, were adept at iden-
tifying which hospitalized patients were likely to die. Just as
nurses should discharge hospital patients, so too ought they to
organize end of life care under ICN’s Basic Principles of Nursing
Care’s mandate on helping individuals experience a peaceful
death. Of all health professionals, only nurses have specifically
identified peaceful death as a domain for practice. Dame Cecily
Saunders of the UK and Florence Wald in America, both nurses,
embraced end of life care through their writings on the modern
hospice movement.
ICD and DRG labels do not explain why nurses spend more or
less time with patients. ICN’s Nursing Service Committee asked
Henderson to explain the standards for the time nurses spend
with individuals, measured in hours. In order for any nurses or
groups to establish standards for nursing care time, they must
first examine the pattern of needs among patients served by the
nurse, agency or institution. Nurses must first record informa-
tion about their patients and then set standards (Table 1).
412 Virginia Henderson Lecture
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4. Nightingale, too, was certain that nurses would systematically
contribute to the information base that would be tabulated by
patient type. She wrote:
“. . . to the experienced eye of a careful observing nurse, the
daily, I had almost said hourly, changes which take place in
patients, and which changes rarely come under the cognizance
of the periodical medical visitor, afford a still more important
class of data, from which to judge of the general adaptation of
a hospital for the reception and treatment of sick.”
Nightingale: Notes on Hospitals, 3rd
ed. pp. 6–7
The time to heed Nightingale’s message is long overdue. In our
era of computers and electronic communication, nurses must
now place themselves in a position to summarize, store and
retrieve this important class of data from the careful observing
nurse. While Nightingale did not specify which data, Virginia
Henderson and ICN Nursing Services Committee were very spe-
cific – nurses are to summarize, store, and retrieve information
about their patients’ fourteen human needs, circumstances
always affecting them, and pathological states that may affect
need.
Two reasons for making the recommendation that nurses sum-
marize and store human need information for later retrieval and
review are to, first, improve patient care and, second, to develop
professional skills. If nurses were to simply count and record how
many of the fourteen human needs the nurse and patient agreed
Table 1 Nurse’s checklist of an individual’s human needs
ICN’s Basic Principles of Nursing Care [4TH
EDITION, 2004, PP. 19–20]©
NEEDS Assistance with:
1 Breathing Normally
2 Eating and Drinking Adequately
3 Eliminating by all Avenues of Elimination
4 Moving and maintaining desirable posture
5 Sleep and Rest
6 Sleep and Rest
7 Maintain body temperature [adjust clothes, change environment]
8 Keep body clean, well-groomed; protect skin
9 Avoid dangers in environment, avoid injuring others
10 Communicate with others expressing emotions, needs, fears
11 Worship according to principles
12 Work to provide a sense of accomplishment
13 Play or participate in recreation
14 Learn, discover, or satisfy curiosity that leads to normal and developmental health
Everpresent Factors Affecting Needs Pathological States sometimes affecting Needs
Age 28 Disturbances in fluid and electrolytes
Temperment 29 Vomiting
15 Euphoric/hyperactive 30 Diarrhea
16 Anxious, fearful, agitated, hysterical 31 Starvation
17 Depressed, hypoactive 32 Acute Oxygen want
Social/Culture: family unit with friends, sta 33 Shock [collapse, hemorrhage]
18 Relatively alone, maladjusted, destitute 34 Disturbances in consciousness [fainting, coma, delirium]
Physical and Intellectual Capacity
19 Underweight 35 Exposure to heat/cold with abnormal body temperature
20 Overweight
21 Sub-normal mentality 36 Acute febrile states [all causes]
22 Gifted mentality 37 Local injury, wound and/or infection
Senses 38 Communicable condition
23 Hearing 39 Pre-op state
24 Sight 40 Post-op state
25 Equilibrium 41 Immobilization from disease or prescribed as treatment
26 Touch
27 Motor power deminished 42 Persistant or intractable Pain
Virginia Henderson Lecture 413
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5. were problematic each day, and ask and record the same question
day after day, they would see the patterns of both patient depen-
dence and progress towards independence. Subsequent observa-
tions and recordings about the patient will help gauge how
effective interventions were. The choice of interventions to meet
any need are numerous; Henderson reviewed these methods, as
well as the research and expert-opinion literature that went into
reports about methods, and then wrote several chapters of her
textbook on each need. The essential link that underlies recom-
mendations to summarize and record for retrieval information
about human needs, is the centrality of the professional literature
to these problems in patients. Were we unsuccessful in managing
needs in patients, we should be reassured that consulting our
literature will offer us a variety of methods to help the patient.
Nurses, too, should reflect on the problems seen in practice so
the literature can be consulted to aid in increasing competence
and knowledge. New methods and techniques are regularly
reported, and these reports are now stored for retrieval in com-
puterized databases. A few clicks of the mouse will afford the
nurse the latest clinical and research information about effective
and demonstrated methods. Even using older citations from her
textbook and entering them into the National Library of
Medicine/National Institutes of Health computer database called
PubMed, the ‘Related Articles’ hypertext function can be used to
access updated journal articles. Hundreds of citations can be
narrowed into a relevant few by coupling the organization of
Basic Principles of Nursing Care and Principles and Practice of
Nursing, 6th
edition, to guide a PubMed computer search.
Patients and their nurses benefit from the application of
knowledge from these two great women, Nightingale and Hend-
erson. It may seem quaint to some to look back 30–150 years to
find relevant direction for the contemporary nurse, but their
trailblazing work is still key to our understanding of the profes-
sion. Statistics were as new to Nightingale as computers are to
many of us. Henderson’s manual compilation of a profession’s
literature and synthesis into a textbook will never be done again,
yet we can rely on her organization to help us systemize knowl-
edge. It is our task to complete the unfinished business of these
two heroic women. Compile statistics about your patients and
store them for retrieval and review. Use ICN’s universal human
needs to categorize patient information and use the categories to
access the literature in order to further develop professional skills
for patient well-being. The process outlined here treats every
nurse as researcher – a vital concept for the future of patient care
(Evans 1980).
ICN versus the WHO
The WHO has taken action on two fronts related to data require-
ments and access to patients. The first occurred when the WHO
published a 2001 manual for classifying functioning, disability
and health, or ICF (WHO 2001). The ICF is a complex version of
what ICN commissioned Henderson to write. A checklist from
ICN’s Basic Principles of Nursing Care, used repeatedly, is an
earlier, more complete version of the WHO ICF instrument
which few now use. The ICN version comes with the content
available in 31 languages and with an army of potential users –
nurses. Were nurses to share that serial information as a compo-
nent of a digital record, policy makers could better judge the
effectiveness of practices designed to improve function, reduce
pain, and help individuals experience peace at life’s end. Perhaps
the WHO should abandon the ICF and enlist ICN to encourage
nurses’ use of the human-needs checklist during each encounter
to record patient information.
The second WHO initiative concerns access to care. It has been
31 years since the 134 member states of the WHO adopted
primary care as the key strategy for achieving ‘health for all’ by
the year 2000 at Alma Ata. The WHO revisited the topic of health
for all in 2008 when it published ‘Primary Health Care – Now
More Than Ever’ (WHO 2008). The challenges revealed in the
new document are those that face nurses; hospital centrism,
fragmentation of care, and unregulated commercialism in health
care. Women must exert greater influence on health care through
WHO, and nurses must lead women. Nurses should see patients
before doctors and provide primary care.
None of the innovations recommended here can be done
without nurses and patients working together. I would describe
what we would do for patients if we had direct access to them
in primary care, using the two sentences Virginia Henderson
wrote:
Nurses help people, sick or well, in the performance of those
activities contributing to health, its recovery (or to a peaceful
death), that they would perform unaided if they had the nec-
essary strength, will or knowledge. Nurses help people gain
independence as rapidly as possible.
I would also show patients Henderson’s 2119-page textbook and
tell them this is what we learn in nursing school.
People today need direct access to nurses for the same reasons
as in the past and for the reason Nightingale founded our pro-
fession – dominant medicine does not provide, nor should phy-
sicians prescribe, all that patients need. Nightingale’s prevention
and relief pertains as much to the communicable diseases of our
era as hers, and to the chronic conditions of those growing old
(Thorpe 2005). We have evidence that nursing works. Nurses
need direct access to patients and ICN should engage the WHO
to develop strategies to ensure primary health care from nurses
becomes the norm.
414 Virginia Henderson Lecture
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6. References
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