Women's History & the Professionalisation of Nursing

Context

The birth of Army nursing took place against a backdrop of an emerging professionalisation of nursing, and the debates for the registration of nurses. Army nurses were active in both of these processes. When we look at the history of Army nurses, or explore a member of our family who was an Army nurse, we need to understand these contexts in order to understand and properly contextualise the materials we are using.

Nursing as a Profession

Early nurse reformers like Florence Nightingale and Louisa Twining, as well as later reformers like Catherine Wood and Mrs Bedford Fenwick, wanted nurses to have good clinical skills but also a set of behaviours that would make them ‘professional’ in their standing. They saw these behaviours as propriety and civility. Propriety being ‘respect for social superiors, punctuality, orderliness, cleanliness, industriousness, efficiency and a certain amount of piety’. Civility was associated with religion, and nursing reformers used the language of religion as was common in Victorian times. They saw civility as a politeness, manners and etiquette which they had seen in nurses from religious orders.

This was echoed in nursing textbooks of this period which often began with an introductory chapter on the moral basis of nursing and the importance of developing the nurse’s virtuous character. It was the second half of the nineteenth century that saw the ‘trained nurse’ emerge, primarily from the twelve London teaching hospitals. These nurses were also described as ‘Nightingale nurses’ having trained in the Nightingale system. These ‘new’ nurses were required not only to meet rising clinical standards, but also to meet financial needs.

At this time there was an increase in the number of doctors, and medical knowledge and skills were developing in a way that required support from educated nurses. The social standing of doctors was increasing, and there were some fears amongst the medical profession about the rising status of nurses. The new nurses helped financially because they retained domestic roles like sweeping, dusting and polishing in the wards. The concerns of the doctors were encapsulated in an editorial in the Lancet of 1880:

Nursing is not a craft: still less can it be regarded as a profession. There are specialties in cooking and other departments of domestic work; and there may, therefore, be professed cooks and waiters, and housemaids, and washer-women, but there ought to be no specialty in nursing, and there can be nothing professional in the work. The sole qualifications required for tending the sick are kindness, gentleness, and quiet cheerfulness of manner, patience, physical strength, a light and dexterous hand, and the sort of intelligence which renders it easy to take in ideas of work quickly, and to pick up ways of doing what has to be done in a cleanly fashion and decently. For the rest the nurse ought to be the servant of the doctor, and should carry out his instructions... The ‘trained nurse’ – that is, the woman trained to nursing as a specialty, is an anomaly. Every scrap of information she posses beyond the mere routine service of sick-tending is not merely useless but mischievous.

This came shortly after the ‘crisis’ at Guy’s Hospital which saw public discord between nursing and medical staff, as both came to terms with the new roles nursing were taking on.

There was less resistance to the Anglican Sisterhoods that took on nursing roles, and who were setting up training schools during this period. Anglican Sisters from St John’s House were contracted to take on the nursing at King’s College Hospital and were very successful. Their principles spread, and by 1866 three of the twelve London hospitals had Anglican Sisters delivering nursing care (King’s College, Charing Cross, and University College Hospitals) . The Anglican Sisterhoods offered a way for ladies to train as nurses as well as middle class women. Hospitals took on paying ‘lady-pupils’ to help alleviate financial concerns. Some of these lady-pupils were rapidly promoted, like Eva Lückes and Ethel Gordon Manson who became matrons of The London Hospital and St Bartholomew’s Hospital respectively.

These lady-pupils who became matrons generally agreed that nursing would be better served if the social class of recruits could be improved. Nursing became bound with social class. Ladies (as discussed above) could not take paid work and working class women were not educated enough to gain professional status. The Anglican Sisterhoods offered training to ladies so that they could become (unpaid) nurses and in this sense bridged the gap in social class. As the rise in middle class educated ladies in nursing increased the shape of the nursing workforce changed. Nurses then came largely from two classes: “Respectable persons of the rank from which upper class servants are usually taken, and a smaller number of more highly educated women, such as, for example, the daughters of professional, or naval and military men”. Brooks viewed these two classes as distinct and hierarchical, “these women (elite, middle class nurses) could inculcate the working class recruits without becoming polluted by them, in much the same way that middle class women could undertake ‘rescue’ work with prostitutes without being contaminated.”

State Registration

In parallel with the debates around the professionalisation of nursing were debates around the need for a single state register of nurses. In relation to the question of registration there were three sets of power relationships at play. These were the employment relationship between hospitals and nurses, where hospitals controlled the length and standard of training as well as pay and conditions. The second was the relationship between medical men and nurses, and the desire of medical organisations to control any statutory nursing body. The last was the gender relationships with a clear link between the self-regulation of nurses and the wider emancipation of women movement.

In 1888 Mrs Bedford Fenwick and Miss Catherine Woods set up the British Nurses Association (BNA) with the intention of promoting and securing both registration for nurses and a central control over the length and standard of nurse training . There were those for and against registration within administrative, medical and nursing sectors. Opponents argued that registration relied upon being tested by examination and that this could not take into account personal qualities, and these were seen as just as important for a ‘good’ nurse. Many hospitals were against a central register because they felt the primary allegiance of a nurse should be to her ‘alma mater’, and that was how the reputation of the big teaching hospitals could be maintained. In some respects, a central register and common standards of training might have removed the control hospitals had over the nurses that they trained.

In 1893 the BNA tried to get Parliament to enforce registration, but they failed. Subsequently they applied to the Privy Council for a Royal Charter and permission to produce their own register. The charter was granted and they became the Royal British Nurses Association (RBNA), but they were only allowed to keep a list of persons who may have applied to be entered on it as nurses. The two sides of the debate can be summarised as the contrast between Nightingale’s vision of nursing “as a dedicated calling more akin to a religion with little importance attached to status and reward” and Mrs Bedford Fenwick’s vision of “occupational professionalism, where occupational expertise brought with it the deserved trappings of status and economic rewards”.

The debate continued right through the period of the Boer War and beyond, and it was not until 1919 that the Nurses Bill was passed, creating the General Nursing Council and state registration of nurses. It is interesting to note that military nurses were involved with the BNA from its inceptions and many are listed in its ‘list of nurses’ including Sister Amy Gordon Mackay who was an early member of the BNA and served on the council, and Sister Helen Thompson Foggo who settled in South Africa after the Boer War and became Lady Consul of the RBNA in South Africa.