US Army Nurse Corps
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The United States Army Nurse Corps (USANC) was formally established by the U.S. Congress in 1901. It is one of the six medical special branches (or " corps") of officers which – along with medical enlisted soldiers – comprise the Army Medical Department (AMEDD). The ANC is the nursing service for the U.S. Army and provides nursing staff in support of the Department of Defense medical plans. The ANC is composed entirely of Registered Nurses (RNs).


Mission

According to the ANC their mission is "To provide responsive, innovative, and evidence-based nursing care integrated on the Army Medicine Team to enhance readiness, preserve life and function, and promote health and wellness for all those entrusted to our care. Preserving the strength of our Nation by providing trusted and highly compassionate care to the most precious members of our military family—each Patient."


Creed

The Army Nursing Team Creed was written by Lt. Col. Leigh McGraw in December 2009:


Qualifications

To qualify for the Army Nurse Corps, an applicant needs a Bachelor of Science in Nursing (BSN) from an accredited program (Active and Reserve). AR 135-100, AR 135-101, AR 601-100, and applicable ANC circulars in the DA Circular 601-FY-X series list qualifications for entry. The ANC consists entirely of commissioned officers. Nurses who wish to serve as Army Nurses are required to hold an unrestricted Registered Nurse (RN) license prior to receiving a commission.


Leadership

As of 2019, the Chief of the Army Nurse Corps is Brig. Gen. Jack M. Davis.


Specialties – Area of Concentration (AOC)

Public Health Nurse – 66B
Psychiatric-Mental Health Nurse – 66C Peri-Operative Nurse – 66E Certified Registered Nurse Anesthetist (CRNA) – 66F Obstetrics-Gynecological Nurse – 66G Medical-Surgical Nursing – 66H Generalist Nurse – 66N; this is used to designate positions on organizational documents but is not held by the individual. Family Nurse Practitioner (FNP) – 66P Additional Skill Identifiers (ASIs); these designate additional areas of expertise or experience and are in addition to a basic nursing specialty. :7T – Clinical Nurse Specialist (CNS) :8A – Critical Care Nurse (ASI to be deleted and converted to the AOC 66S) :8D – Nurse Midwife (Only used in conjunction with AOC 66G) :M5 – Emergency Nurse (ASI to be deleted and converted to the AOC 66T) :M8 – Psychiatric Nurse Practitioner (Only used in conjunction with AOC 66C) :M9 – Nurse Case Manager :N1 – Aviation Medicine Nurse Practitioner (Only used in conjunction with AOC 66P)


History

*The Army Nurse Corps became a permanent corps of the Medical Department under the Army Reorganization Act (31 STat. 753) passed by Congress on 2 February 1901.


Pre-1901

Nurses served in Washington's Army during the Revolutionary War. Although the women who tended the sick and wounded during the Revolutionary War were not nurses as known in the modern sense, they blazed the trail for later generations when, in 1873, civilian hospitals in America began operating recognized schools of nursing. After the Revolutionary War, Congress drastically reduced the size of the medical service. Patient care was performed by soldiers detailed from the companies. There was no centralized medical direction by a formally organized medical department until the War of 1812. The Army Medical Department was reestablished by Congress under the direction of a Surgeon General, Dr. Joseph Lovell. The Army Reorganization Act of 1818 marked the beginning of the modem Medical Department of the United States Army. Two months after the Civil War began on 12 April 1861, the Secretary of War Simon Cameron appointed
Dorothea Lynde Dix Dorothea Lynde Dix (April 4, 1802July 17, 1887) was an American advocate on behalf of the indigent mentally ill who, through a vigorous and sustained program of lobbying state legislatures and the United States Congress, created the first gene ...
as superintendent of women nurses for the Union Army. Some of the women, before reporting for assignment, received a short course in nursing under the direction of Dr. Elizabeth Blackwell, the first woman to receive a medical degree in the United States. Some of the nurses who worked in the Union hospitals were not on the Army payroll but were sponsored by the United States Sanitary Commission or by volunteer agencies. Their work was largely limited to preparing diets, supervising the distribution of supplies furnished by volunteer groups, and housekeeping details. During the 1898 Spanish–American War, the Army hired female civilian nurses to help with the wounded. Dr. Anita Newcomb McGee was appointed Acting Assistant Surgeon in the U.S. Army. After the war ended, McGee pursued the establishment of a permanent nurse corps. She wrote the section of the Army Reorganization Act legislation pertaining to nursing and is now known as the founder of the Army Nurse Corps. In all, more than 1,500 women nurses worked as contract nurses during that 1898 conflict. Race and sex played central roles. The ANC was for white women only and fought hard to exclude or minimize the number of black women until 1947. They excluded all men until the Korean war when male doctors began to emphasize the need for nurses in the front lines, and this meant male nurses.


1901–1917

Professionalization was a dominant theme during the Progressive Era, because it valued expertise and hierarchy over ad-hoc volunteering in the name of civic duty. The Army Nurse Corps (female) became a permanent corps of the Medical Department under the Army Reorganization Act (31 Stat. 753) on 2 February 1901. Nurses were appointed in the Regular Army for a three-year period, although nurses were not actually commissioned as officers in the Regular Army until forty-six years later-on 16 April 1947. Dita H. Kinney, was officially appointed the first Superintendent of the Corps on 15 March 1901. Kinney served as superintendent until she resigned on 31 July 1909. The number of nurses on active duty hovered around 100 in the years after the creation of the corps, with the two largest groups serving at the general hospital at the Presidio in San Francisco and at the First Reserve hospital in Manila.


World War I

In World War I (American participation from 1917–18) the military recruited 20,000 registered nurses (all women) for military and navy duty in 58 military hospitals; they helped staff 47 ambulance companies that operated on the Western Front. More than 10,000 served overseas, while 5,400 nurses enrolled in the Army's new School of Nursing. Key decisions were made by Jane Delano, director of the Red Cross Nursing Service,
Mary Adelaide Nutting Mary Adelaide Nutting (November 1, 1858 – October 3, 1948) was a Canadian nurse, educator, and pioneer in the field of hospital care. After graduating from Johns Hopkins University's first nurse training program in 1891, Nutting helped to found ...
, president of the American Federation of Nurses, and
Annie Goodrich Annie Warburton Goodrich (February 6, 1866December 31, 1954) was an American nurse and academic. She was born in New Brunswick, New Jersey and grew up in Hartford, Connecticut. Her grandfather was John S. Butler.Judith Schiff,Yale's first femal ...
, dean of the Army School of Nursing.


Interwar period

Demobilization reduced the two corps to skeleton units designed to be expanded should a new war take place. Eligibility at this time included being female, white, unmarried, volunteer, and a graduate from a civilian nursing school. In 1920, Army Nurse Corps personnel received officer-equivalent ranks and wore Army rank insignia on their uniforms. However, they did not receive equivalent pay and were not considered part of the US Army. Flikke remained in the Army after the war. After 12 years at Walter Reed Army hospital in Washington, D.C., she was promoted to captain and became the Assistant Superintendent of Nurses. She succeeded in creating new billets for occupational therapists and dieticians. Flikke became Superintendent, with the rank of Major, in 1938.


World War II

At the start of the war in December 1941, there were fewer than 1,000 nurses in the Army Nurse Corps and 700 in the Navy Nurse Corps. All were women. Colonel Flikke's small headquarters in 1942, though it contained only 4 officers and 25 civilians, supervised the vast wartime expansion of nurses, in cooperation with the Red Cross. She only took unmarried women age 22–30 who had their RN training from civilian schools. These nurses were commissioned for a term that lasted the duration of the war plus six months, but they were discharged if they married or became pregnant. Due to the Japanese attack of Pearl Harbor on 7 December 1941, the United States entered the Pacific part of World War II. Along with this military effort was the work of the Flying Tigers in Kunming, China, under Claire Chennault. Nurses were thus needed in China to serve the U.S. Army. These nurses were recruited among the Chinese nurses residing in China, particularly the English-speaking nurses that fled Hong Kong (a British colony) to free China due to the Japanese invasion of Hong Kong on 8 December 1941. The Hong Kong nurses were trained by the Department of Medical Services (directed by Dr. Percy Selwyn Selwyn-Clarke) of the Government of Hong Kong. They took up Nursing positions at the Flying Tigers (Rebecca Chan Chung 鍾陳可慰, Daisy Pui-Ying Chan 陳培英), U.S. Army (Rebecca Chan Chung 鍾陳可慰, Daisy Chan 陳培英, Cynthia Chan 陳靜渝), Chinese Red Cross (Elsie Chin Yuen Seetoo, Irene Yu 余秀芬) and China National Aviation Corporation (Rebecca Chan Chung 鍾陳可慰, Irene Yu 余秀芬). Cynthia Chan 陳靜渝 is the elder sister of Anna Chan 陳香梅 ( Mrs. Chennault). Only a few African American nurses were admitted to the Army Nurse Corps.
Mabel Keaton Staupers Mabel Keaton Staupers (February 27, 1890 – September 30, 1989) was a pioneer in the American nursing profession. Faced with racial discrimination after graduating from nursing school, Staupers became an advocate for racial equality in the nurs ...
, who worked for the
National Association of Colored Graduate Nurses The National Association of Colored Graduate Nurses was a professional organization for African American nurses founded in 1908. Foundation In 1906, Connecticut nurse Martha Minerva Franklin surveyed African American nurses to see what challenges ...
with help from Eleanor Roosevelt, pressured the Army to admit African American nurses in 1941. The first black nurse admitted to the program was
Della H. Raney Della Hayden Raney (January 10, 1912 – October 23, 1987) was an American nurse in the Army Nurse Corps. Raney was the first African American nurse to report for duty in World War II and the first to be appointed chief nurse. In 1944, she beca ...
who was commissioned as a second lieutenant in April 1941. The limit on black nurses was 48 in 1941 and they were mostly segregated from white nurses and soldiers. In 1943, the Army set a limit on black nurses to 160. That same year, the first African American medical unit, the
25th Station Hospital Unit The 25th Station Hospital was an all African American unit of nurses who served in the Army Nurse Corps during World War II. The unit was the first African American group sent overseas and were stationed for a short tour in Liberia in 1943. ...
, was deployed overseas to
Liberia Liberia (), officially the Republic of Liberia, is a country on the West African coast. It is bordered by Sierra Leone to Liberia–Sierra Leone border, its northwest, Guinea to its north, Ivory Coast to its east, and the Atlantic Ocean ...
. Later, nurses were deployed to Burma, where they treated black soldiers. African American nurses also served in China,
Australia Australia, officially the Commonwealth of Australia, is a Sovereign state, sovereign country comprising the mainland of the Australia (continent), Australian continent, the island of Tasmania, and numerous List of islands of Australia, sma ...
, New Guinea, the Philippines, England and in the US where they treated
prisoners of war A prisoner of war (POW) is a person who is held Captivity, captive by a belligerent power during or immediately after an armed conflict. The earliest recorded usage of the phrase "prisoner of war" dates back to 1610. Belligerents hold priso ...
. By the end of the war, there were 476 serving in the corps. On 26 February 1944 Congress passed a bill that granted Army and Navy Nurses actual military rank, approved for the duration of the war plus 6 months. With over 8 million soldiers, sailors, and airmen, the needs were more than double those of World War I. Hundreds of new military hospitals were constructed for the expected flow of casualties. Fearing a massive wave of combat casualties once Japan was invaded in late 1945, President Franklin D. Roosevelt called on Congress early in 1945 for permission to draft nurses. However, with the rapid collapse of Germany early in 1945, and the limitation of the war in the Pacific to a few islands, the draft was not needed and was never enacted. By the end of the war, the Army and Army Air Forces (AAF) had 54,000 nurses, and the Navy had 11,000—all women. Some 217 black nurses served in all-black Army medical units. The AAF was virtually autonomous by 1942 and likewise was its Nurse Corps. Much larger numbers of enlisted men served as medics. These men were in effect practical nurses who handled routine care under the direction of nurse officers. Likewise many enlisted Wacs and Wafs served in military hospitals. Medical advances greatly increased survival rates for the wounded: 96% of the 670,000 wounded soldiers and sailors who made it to a field hospital staffed by nurses and doctors survived their injuries. Amputations were seldom necessary to combat gangrene. Penicillin and sulfa drugs proved highly successful in this regard. Nurses were deeply involved with post-operative recovery procedures, air evacuation, and new techniques in psychiatry and anesthesia. Upon Flikke's retirement in 1943, she was succeeded by
Florence A. Blanchfield Florence Aby Blanchfield (April 1, 1884 in Shepherdstown, West Virginia – May 12, 1971 in Washington, D.C.) was a United States Army Colonel and superintendent of the Army Nursing Corps, from 1943 to 1947. She was awarded the Distinguished Se ...
, who successfully promoted new laws in 1947, that established the Army, Navy, and Air Force Nurse Corps on a permanent basis, giving the nurses regular commissions on exactly the same terms as male officers. A month before she retired in 1947, Blanchfield became the first woman to hold a regular Army commission.


Prisoners of war


Korea

During the Korean War, Army nurses would once again treat the wounded. Nurses would staff MASH units and standard emplaced hospitals in Japan and Korea. Nurses were on the forefront of battlefield medicine during the conflict, playing a major role in the treatment of the wounded U.N. forces within mere minutes or hours of the wounds being inflicted. In September 1955, President Eisenhower suffered a heart attack while on vacation near Denver. He was hospitalized at
Fitzsimons Army Medical Center Fitzsimons Army Hospital, also known as Fitzsimons General Hospital and renamed Fitzsimons Army Medical Center (FAMC) in 1974, was a U.S. Army facility located on in Aurora, Colorado. The facility opened in 1918 and closed in 1999. The grounds w ...
. During his six weeks of recovery, Ike talked to his Army nurses. He discovered their quarters were substandard, that nurses rotated overseas more often than other soldiers and they were forced to leave the military at age fifty-five. Nurses were also promoted more slowly than other soldiers. Ike directed the corps be led by a brigadier general and that the other issues be corrected.


Vietnam

The Army Nurse Corps stopped being all-female in 1955; that year Edward L.T. Lyon was the first man to receive a commission in the Army Nurse Corps. During the Vietnam War many Army nurses would see deployment to South East Asia. Army nurses would staff all major Army hospitals in the theatre, including: Cam Ranh Bay,
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, and
Saigon , population_density_km2 = 4,292 , population_density_metro_km2 = 697.2 , population_demonym = Saigonese , blank_name = GRP (Nominal) , blank_info = 2019 , blank1_name = – Total , blank1_ ...
. Vietnam would be the first major deployment of men as nurses into the combat theater, as men could be located in more hazardous locations than what was considered safe for females. Many Army nurses faced enemy fire for the first time due to the unconventional nature of the conflict, and several nurses would die from direct enemy fire. On at least one occasion the US Army hospital at Cam Ranh Bay was assaulted and severely damaged, with a loss of both patient and staff life.


Currently

Army Nurses are deployed all over the world, participating in humanitarian missions, and supporting the
Global War on Terror The war on terror, officially the Global War on Terrorism (GWOT), is an ongoing international counterterrorism military campaign initiated by the United States following the September 11 attacks. The main targets of the campaign are militant I ...
.


Modern Nurse Corps

The Nurse Corps continues as a significant part of the Army Medical Department. Most training is conducted at Fort Sam Houston, Texas.


Insignia and badges

The Nurse Corps has a distinctive insignia, a gold color metal
caduceus The caduceus (☤; ; la, cādūceus, from grc-gre, κηρύκειον "herald's wand, or staff") is the staff carried by Hermes in Greek mythology and consequently by Hermes Trismegistus in Greco-Egyptian mythology. The same staff was also ...
, bearing an 'N' in black enamel.


Superintendents and Chiefs

From its founding in 1901 until after World War II in 1947, the Army Nurse Corps was led by a superintendent. Its nurses had no permanent commissioned rank. The Army-Navy Nurses Act took effect on 16 April 1947, establishing the Army Nurse Corps as a staff corps, with officers holding permanent commissioned ranks from second lieutenant to lieutenant colonel. The corps was to be led by a director holding the rank of colonel while in that position.


List of Superintendents of the Army Nurse Corps


List of Chiefs of the Army Nurse Corps

Source:


Army Nurse Corps officers

* Dorothea Dix – First Superintendent of Army Nurses * Cornelia Hancock – civilian nurse serving the Union Army during the American Civil War, injured in battle. * Dr.
Mary Edwards Walker Mary Edwards Walker, M.D. (November 26, 1832 – February 21, 1919), commonly referred to as Dr. Mary Walker, was an American abolitionist, prohibitionist, prisoner of war and surgeon. She is the only woman to ever receive the Medal of Honor. ...
– served as a civilian nurse during the American Civil War, became the Army's first female surgeon and Medal of Honor recipient. * Susie Taylor – first African American Army nurse. *
Clara Maass Clara Louise Maass (June 28, 1876 – August 24, 1901) was an American nurse who died as a result of volunteering for medical experiments to study yellow fever. Early life Clara Maass was born in East Orange, New Jersey, to German immigrant ...
– contract nurse for the Army during the Spanish–American War, died participating in an army yellow fever study. * Anita Newcomb McGee – a physician, she became the acting assistant Army surgeon in charge of nursing during the Spanish–American War. Helped to write some of the legislation that eventually created the Army Nurse Corps. *
Anna Maxwell Anna Caroline Maxwell (March 14, 1851January 2, 1929), was a nurse who came to be known as "the American Florence Nightingale". Her pioneering activities were crucial to the growth of professional nursing in the United States. Early years Maxwell ...
– instrumental in the establishment of the Army Nurse Corps. * 1st Lt.
Reba Cameron Rebecca G. Cameron (1885-1959), known as Reba G. Cameron, was a Canadian-born American Army nurse who was awarded the Army Distinguished Service Medal for her military hospital work during World War I. She also worked in the Philippines and Japan. ...
— career Army nurse, recipient of the
Distinguished Service Medal Distinguished Service Medal (DSM) is a high award of a nation. Examples include: *Distinguished Service Medal (Australia) (established 1991), awarded to personnel of the Australian Defence Force for distinguished leadership in action * Distinguishe ...
for her work in World War I. * Adah Belle Thoms – instrumental in gaining the right of African American nurses to serve in Army Nurse Corps. * 1st Lt. Annie Fox – first woman to receive the Purple Heart for actions during Pearl Harbor. This award was later converted to a Bronze Star when the criteria for the Purple Heart changed. * Col.
Ruby Bradley Colonel Ruby Bradley (December 19, 1907 – May 28, 2002) was a United States Army Nurse Corps officer, a prisoner of the Japanese in World War II, and one of the most decorated women in the United States military. She was a native of Spencer, ...
– one of the most decorated female officers for service in World War II and Korea. * LT
Diane Carlson Evans Diane Carlson Evans (born 1946) is a former nurse in the United States Army during the Vietnam War and the founder of the Vietnam Women's Memorial Foundation, which established the Vietnam Women's Memorial located at the Vietnam Veterans Memoria ...
– Vietnam era nurse, founder of th
Vietnam Woman's Memorial Foundation
* CPT
María Inés Ortiz Captain María Inés Ortiz (April 24, 1967 – July 10, 2007) was the first American nurse to die in combat during Operation Iraqi Freedom and the first U.S. Army nurse to die in combat since the Vietnam War. The United States Army named the For ...
– first nurse to die in combat since Vietnam, killed in Iraq July 2007. * LT
Ruth M. Gardiner Ruth M. Gardiner (May 20, 1914 – July 27, 1943) was a nurse in the United States Army Nurse Corps. She served in the Alaskan Theater and rose to the rank of Second Lieutenant. Gardiner was the first Army Nurse Corps' flight nurse killed whil ...
- first nurse to die in action during World War II, killed in Alaska July 1943. * Lt Col Rae Landy - pioneering Hadassah nurse in Palestine, career Army Nurse *
E. Ann Hoefly Brigadier General Ethel Ann Hoefly (March 8, 1919 – August 3, 2003) was an American nurse and member of the United States Air Force. She served with the United States Army Nurse Corps during World War II and volunteered for service in the Eur ...
- served as a nurse in World War II and was later chief of the
US Air Force Nurse Corps The U.S. Air Force Nurse Corps ensures the health of military personnel and their family members. Entry requirements New members of the Air Force Nurse Corps are required to hold at minimum a Bachelor of Science in Nursing (BSN) degree prior to rec ...
.


See also

* United States Navy Nurse Corps * United States Air Force Nurse Corps *
Mobile Army Surgical Hospital Mobile Army Surgical Hospitals were U.S. Army field hospital units conceptualized in 1946 as replacements for the World War II-era Auxiliary Surgical Group hospital units, which had become obsolete. MASH Units were in operation from the Korean ...
(MASH) * Combat Support Hospital (CSH) * Field Hospital * Army nursing (disambiguation) *
Vietnam Women's Memorial The Vietnam Women's Memorial is a memorial dedicated to the nurses and women of the United States who served in the Vietnam War.Schmitt, Eric. "A Belated Salute to the Women Who Served." ''New York Times''. Late ed. November 12, 1993. 1+.Biggins, ...
* Women in Military Service for America Memorial *
Charlotte Edith Anderson Monture Charlotte Edith Anderson Monture (10 April 1890 – 3 April 1996), known simply as Edith Monture,Conn, Heather. 2017.Edith Monture" '' The Canadian Encyclopedia''. Historica Canada. was a Mohawk WWI veteran, known as the first Indigenous-Canadia ...
* National Association of Army Nurses of the Civil War


References


Further reading

* Campbell, D'Ann. ''Women at War with American: Private Lives in a Patriotic Era.'' Cambridge, MA: Harvard University Press, 1984. * Campbell, D'Ann . "Servicewomen of World War II," ''Armed Forces and Society'' (Win 1990) 16: 251–270. * Flikke, Julia. ''Nurses in action'' (1943) 239 pages * Gillett, Mary C. (1981)
''The Army Medical Department, 1775–1818''
Washington, DC: United States Army Center of Military History, United States Army. (Series:
Army Historical Series An army (from Old French ''armee'', itself derived from the Latin verb ''armāre'', meaning "to arm", and related to the Latin noun ''arma'', meaning "arms" or "weapons"), ground force or land force is a fighting force that fights primarily on ...
) * Gillett, Mary C. (1987)
''The Army Medical Department, 1818–1865''
Washington, DC: Center of Military History, United States Army. (Series: Army Historical Series) * Gillett, Mary C. (1995)

Washington, DC: Center of Military History, United States Army. (Series: Army Historical Series) * Gillett, Mary C. (2009)

Washington, DC: Center of Military History, United States Army. (Series: Army Historical Series) * Krueger, David G. (2019), "The Red Cross, the Daughters of the American Revolution, and the Origins of the Army Nurse Corps in the Spanish-American War." Journal of Military History, VOL 83, Issue 2, p. 409-434. * Center of Military History
''The Army Nurse Corps''
Washington, DC: Center of Military History, United States Army. * Monahan, Evelyn and Rosemary Neidel-Greenlee. ''And If I Perish: Frontline U.S. Army Nurses in World War II.'' New York: Knopf, 2003. * Norman, Elizabeth. ''We Band of Angels: The Untold Story of American Nurses Trapped on Bataan by the Japanese.'' New York: Random House, 1999. * Sarnecky, Mary T. ''A History of the U.S. Army Nurse Corps'' (U of Pennsylvania Press, 1999), the standard scholarly history * Threat, Charissa J. ''Nursing Civil Rights: Gender and Race in the Army Nurse Corps.'' Urbana, IL: University of Illinois Press, 2015. * Tomblin, Barbara Brooks. ''G.I. Nightingales: The Army Nurse Corps in World War II'' (2004) 272 page
excerpt and text search
* Vuic, Kara D. ''Officer, Nurse, Woman: The Army Nurse Corps in the Vietnam War.'' Baltimore, MD: Johns Hopkins University Press, 2009.


External links

;Contemporary unit
U.S. Army Nurse Corps official homepage
(on U.S. Army official website).
Army Nurse Corps InfoFM 1, The Army (14 June 2005)Army ValuesThe Army Nurse Corps Association
;History *
American Nurse's Association: Hall of Fame
* ttp://www.blitzkriegbaby.de/ Army Nurse Corps history and WWII women's uniforms in color(WAC, WAVES, ANC, NNC, USMCWR, PHS, SPARS, ARC and WASP)
WW2 U.S. Medical Research CentreUS Army Nurse Corps Collection
US Army Heritage and Education Center, Carlisle, Pennsylvania
Viet-Nam Women's MemorialWomen's War Memorial
personal account of life on the Comfort, including the kamikaze strike, from last known surviving ARMY nurse, 1st Lt. Doris Gardner (Howard). * * * * * {{Authority control Army medical administrative corps
Nurse Corps Most professional militaries employ specialised military nurses. They are often organised as a distinct nursing corps. Florence Nightingale formed the first nucleus of a recognised Nursing Service for the British Army during the Crimean War in 1854 ...
United States Army Nurse Military nursing Nursing organizations in the United States