Health and the Division of Labour

Margaret Stacey, Margaret Reid, Christian Heath, Robert Dingwall

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781138483330
• eBook ISBN: 9781351055123
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

Originally published in 1978, Health and the Division of Labour examines problems and tensions experienced in health work. The papers analyse inter- and intra-occupational rivalry and consider the impact of new forms of managerial rationality upon the traditional divisions of tasks and prestige in health work. The issues raised here affect public policy in both Britain and the USA: Americans can profit from British work on the position of women in medicine, on unionisation and on managerialism, Britons can learn from Americans work on the political context of both social science and medicine, in looking at renal dialysis policy and at the problems of fieldwork in Latin America.

The New Managerialism and Professionalism in Nursing

Michael Carpenter

Introduction

This paper discusses some significant contemporary developments in British nursing, set against an historical background. Although an outstanding historical survey exists,¹ that work is now some years old and, contains little theory on the development of nursing. Occupational politics in the context of changes in occupational content needs emphasising and the familiar picture of an occupation almost totally resistant to change requires considerable modification.

At present there is accelerating change in the NHS, in nursing itself and in society as a whole. It cannot be overemphasised, therefore, that the conclusions and predictions based on contemporary developments are provisional.

The Creation of an Occupational Community

It is a commonplace in labour economics that the provision of occupational services depends on the intersection of the forces of demand and supply. The emergence of nursing at the end of the nineteenth century in the voluntary hospitals is almost a textbook example, just as the later loss of impetus in nursing reform was in many ways due to these forces coming into more or less permanent disequilibrium.

On the supply side, the story has often been narrated of substantial numbers of unmarriageable middle-and upper-middle-class women becoming a burden to their parents. Victorian England was characterised by contradictory developments. On the one hand there was the romantic celebration of the nobility of ‘womanhood’. This had many precedents, but it was encouraged by the development among the bourgeoisie of the idea of the ‘family’ as a ‘refuge’, to which they could escape at least temporarily from the competitive baseness of the world of Capital. At the same time, there were the first stirrings of women’s consciousness, as these women saw a life spread before them without any real social functions.

Nursing emerged as a compromise. Although some leading individuals were involved in the feminist movement, the main thrust of nursing reform was largely congruent with the prevailing male definitions of womanhood. Nursing enabled the desire for some measure of self-determination to be realised in terms agreeable to the prevailing male imagery of women. The work itself was not to be tainted with the world of Capital. It was to be carried out as a service and pecuniary motives were to play no part, just as the home was supposed to be the place where goods and services were provided for love, not money. But work in hospitals exposed women to intimate contact with male patients, and put them in close proximity to male doctors. The cloistered separateness of the nursing community served to reassure anxious fathers and was probably decisive in many cases in them allowing their daughters to leave home and take up nursing. The espousal of religious virtues helped to protect the nurse during intimate contact with male patients. The class distance between these women and the majority of their patients, and the ban on ‘familiarity’ were reinforcing factors. The rigid discipline and the seclusion in the nurses’ home, were also part of a network of devices which served to protect the fragile notions of womanhood from the world at large and, more particularly, from doctors. Increasing numbers of these women exchanged one rigidly authoritarian environment for another, compensated by some promise of social worth.

This occupational infrastructure helped to change the existing image of the nurse from a generally disreputable character to that of a ministering angel. It helped to make available a sufficient supply of ladies (and aspiring ladies) for nurse training in the voluntary hospitals. Clearly, however, ‘demand’ factors were equally important. Nursing reform depended not only on there being work which was either not being done or not being done adequately, but also on the resources nursing leaders could deploy against opponents. In the voluntary hospitals these conditions were more or less met, resulting in the intersection of the forces of demand and supply.

A vacant occupational space occurred initially because reformers could claim that the somewhat diverse elements which were to make up the new occupation (delegated treatments from doctors, care of patients’ physical needs, the maintenance of the ward in a clean and proper condition, and so on) could be viewed as a unified whole, in terms of the ‘sanitary idea’. This idea emerged before, but was systematised scientifically by the acceptance of the germ theory of disease, which was an important ideal of social reform generally in the nineteenth century. The theory meant that the health of the working class could no longer be ignored by the higher orders, for infective disease was not a ‘respector of persons’. As Celia Davies has pointed out, the sanitary idea formed the knowledge basis of early nursing.²

The emphasis on ‘hygiene’ had a number of important consequences for the claim to occupational recognition. It meant first that ‘the proper duties of the nurse’ straddled both the scientific and the non-scientific worlds. The vocational idea that care of the sick and attention to their needs was noble in itself was certainly present. Just as important was the idea that nurses should either understand the importance of hygiene in carrying out all their various menial and less menial duties, or that those who did understand should control those who carried them out. At the outset, therefore, nursing tasks were defined less by what they involved, and more by the principles underlying them. Even the scrubbing of floors was partly lit by the glow of medical science. The principles of medical science had to be transmitted to nurses in their training, although deep divisions emerged among nursing leaders on the necessary extent of this training. The implementation of this knowledge required military organisation and regimentation in the battle against disease. It meant controlling rather than indulging patients, in the interests of hygiene.

The beauty of the idea lay in its simplicity, serving in turn to unify the occupation into a single community stretching from the lowest ranking to the highest ranking nurse. The crucial element in the situation was the power of the matron. As Nightingale wrote: ‘The whole reform in nursing both at home and abroad has consisted in this; To take all power over the nursing out of the hands of the men, and put it into the hands of one female trained head and make her responsible for everything (regarding internal management and discipline)’ (emphasis in the original).³ The power lodged in the single figure was a means of practical reform. As upper-class women the matrons were able, if required, to go above the heads of stewards, and sometimes even doctors, to influence social peers on the Boards of Governors and beyond. They used their powers to bring to heel or if necessary replace (under the banner of the sanitary idea) the existing nursing staff and domestics on the wards. At the same time they recognised the importance of obedience in clinical matters to the doctors, while asserting partial autonomy by insisting that physicians could not themselves directly discipline nurses.

At this time doctors were becoming increasingly interested in the diagnostic aspects of illness rather than treatment, and were thus prepared to allow some functions to be delegated under their control. They were little interested in and ill-equipped by their training to deal with matters of ward and hospital administration. Then, as now, their focus was largely upon symptoms. The emergence of a new occupation which was prepared humbly to carry out clinical and administrative tasks offered great advantages for doctors.

What emerged was the reproduction of the Victorian class structure in the hospital, based on the division of labour between the sexes, and between women of different classes. With the initial advances in medical science and the new forms of social organisation which developed in voluntary hospitals at the end of the nineteenth century, the idea took root that the process of ‘cure’ was separate from and superior to that of ‘care’. Sex, class and later racial insignia were attached to this division as the basis for hospital stratification. Cure functions were seen as primarily male and upper class, and care functions predominantly lower class and/or female but, initially at least, carried out under the moral leadership of upper-class women. The social position occupied by the matron in the hospital power structure, involving the supervision of the majority of aspects of the care structure, bore a close relation to the position she might have occupied, as an upper-middle-class woman in the Victorian home, had she married. In claiming supreme authority over all female staff there was the precedent of the lady of the house, whose supervision of servants complemented but did not subvert the authority of her husband.⁴

Thus towards the end of the nineteenth century the term ‘matron’ took on a new and additional meaning. Previously it had meant powers exercised in an institution by virtue of being the wife of the steward. In the voluntary hospitals, matrons exercised a new power by becoming the symbolic wife of the doctor, and in so doing helped to establish a sphere of autonomy and not just submission. The matron’s autonomy lay chiefly in the managerial control of those under her. Over those she ruled there were basically two strands of legitimation. For some there was the promise of career and a future position of rank, either as a matron or ward sister. In the early days promotion was especially rapid for the Lady Pupils who paid for their training, many of whom became matrons almost on completion of training. For those at the base of the care structure, the lower-ranking nurses and maids, the matron must have been legitimated as mistress of the house.

The imagery of nursing was almost perfectly adapted to the power realities of the voluntary hospitals, and the definition of what was nurses’ work was sufficiently flexible to expand to fit the available jobs to be done. Yet nursing tasks remained unified because of the sanitary idea. Besides, nursing encompassed a fairly limited range of activities. The varieties of clinical treatments and drugs were not great in comparison with today, and the managerial abilities required were largely routine. Most of all there was just hard, unremitting work, the basic essentials of which did not vary greatly from one nursing situation to the next. At this time the total body of knowledge required by a nurse was within the capacities of a single intelligent person, which made the matron into a universalistic nursing authority: an educator, administrator and repository of experience, but first of all a nurse. It was on this basis that nurses once trained were able to carry out nursing reforms in any likely setting.

Setbacks and Survival

The many factors which came together in the voluntary hospitals were either absent or only partially present elsewhere. There were considerable obstacles to the kinds of nursing reforms desired by the emergent élite, which had established itself in the voluntary hospitals. In this paper two selective examples are followed through: the workhouse hospitals and the asylums. A more thorough historical account would cover other areas more extensively. The obstacles were of two kinds: an often radically different balance of power in other settings, combined with changing circumstances in society as a whole.

The most important of the latter forces lay in the fact that the voluntary hospital élite were pressing the state for some kind of professional autonomy, although divided among themselves to some extent, at the same time that the state was assuming greater responsibility for health care, a process considerably hastened by the First World War. Many nurses had to be found and trained quickly during the war. They were admitted in large numbers as Voluntary Aid Detachments (VADs), many of whom posed problems of assimilation to the register of nurses, finally established after the war, and considerable professional pressure was exerted against such ‘dilutees’. This issue was not resolved finally until the newly-formed Ministry of Health enforced the rights of VADs and others to be admitted to the register. Neither should it be overlooked that this also took place at a time of swingeing cuts in public expenditure in the 1920s. The claim for some kind of autonomy was trapped in the contradiction that the state was assuming greater responsibility for health care at the same time that it was cutting back on its cost. This was an unfortunate conjuncture of circumstances for the occupational élite.

Many of the wider social forces were more localised in effect, however. Towards the end of the nineteenth century pauperism and ill health began to be distinguished and the inappropriateness of the doctrines of ‘less-eligibility’ for dealing with the sick, the old and the insane were slowly acknowledged. Yet in the absence of any massive central funding, which did not really occur until 1948, reform was resisted locally by the middle class concerned at the rise in the poor rate. This was compounded by the long years of recession in the last decades of the nineteenth century.

In addition to these difficulties, nurse reformers in workhouse hospitals found less of a vacant occupational space then they had in the voluntary hospitals. There was an established professional management of a sort: the workhouse masters. In addition medical officers more often combined administrative and clinical duties. Even the preparedness of Nightingale nurses to work for low wages could scarcely compete with the even more inexpensive pauper nurse. In any case, work-house masters often preferred pauper nurses because they could be more easily controlled than trained nurses. Well into the twentieth century masters rather than matrons were in control of nurses. In fact, under the poor law regulations they were called Nursing Superintendents, indicating their more limited role.⁴

The situation in the asylums was a little different, and the élite experienced some success. During the early 1900s, often with the connivance of psychiatrists, Nightingale-trained nurses were brought in as assistant matrons or matrons. A full account and explanation of these events must wait detailed historical research. However, it seems that two factors were of great significance. At around this time the medical model of psychiatric disorder was beginning its ascendancy. Further, women nurses were being brought in to implement newer methods of treatment based less on physical coercion, even though it is now apparent that the Nightingale nurses brought their inappropriate bureaucratic rigidities with them, in what has been called the ‘hospitalisation’ of the asylums.

This was an early example of a trend of some importance in the development of twentieth-century nursing. The original adaptability of nursing was nevertheless unified under the sanitary idea. Nursing gradually assimilated many diverse sets of responsibilities that had increasingly little connection with the ori...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Introduction
• The Futures of Professionalisation
• The Role of the Medical Profession in a Non-Democratic Country: The Case of Spain
• Home Dialysis and Sociomedical Policy
• Responsibility in General Practice
• Women in the Medical Profession: Whose Problem?
• The Division of Labour among the Mental Health Professions – a Negotiated or an Imposed Order?
• The New Managerialism and Professionalism in Nursing
• Management, the Professions and the Unions: A Social Analysis of Change in the National Health Service
• Misapplied Cross-Cultural Research: A Case Study of an Ill-Fated Family Planning Research Project