An Introduction to the Social History of Nursing

Robert Dingwall, Anne Marie Rafferty, Charles Webster

• Publisher: Routledge
• Year: 2002
• Print ISBN: 9781138140110
• eBook ISBN: 9781134978700
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

In recent years the study of nursing history in Britain has been transformed by the application of concepts and methods from the social sciences to original sources. The myths and legends which have grown up through a century of anecdotal writing have been chipped away to reveal the complex story of an occupation shaped and reshaped by social and technological change. Most of the work has been scattered in monographs, journals and edited collections.

The skills of a social historian, a sociologist and a graduate nurse have been brought together to rethink the history of modern nursing in the light of the latest scholarship. The account starts by looking at the type of nursing care available in 1800. This was usually provided by the sick person's family or household servants. It traces the interdependent growth of general nursing and the modern hospital and examines the separate origins and eventual integration of mental nursing, district nursing, health visiting and midwifery. It concludes with reflections on the prospects for nursing in the year 2000.

Chapter one
Nurses and Servants

If you could travel backwards in time to 1800, what would the health care system look like? The first thing to grasp is that it would not look like a system at all. Since 1948, most of us have grown up with a pretty clear idea of what a hospital is, what a doctor is, what a nurse is, and so on. In our lifetime there has been a fair degree of consensus about what is and is not valid and reliable medical knowledge. If you looked at health care in 1800, you would find that none of these assumptions hold true. There was no generally accepted body of medical knowledge so that rival theories circulated freely and competitively. There was no legal definition of a doctor and few restrictions on the practice of healing. The Royal Colleges of Physicians and Surgeons and the Society of Apothecaries all competed to licence suppliers of medical treatment and to protect the privileges of those whom they had admitted. However, they would only have served relatively well-off people living in or near major towns. Elsewhere, medical care would be given by family members, especially women, using treatments handed down in the local community or taken from books of home remedies, or by anybody from the neighbourhood who could build up some reputation as a healer, a bonesetter, a herbalist, or a midwife. These might be ordinary villagers or people with some education like a parson or a squire, or their wives. Even among the elite physicians, only the most successful healers could work full-time and make a living at this trade (Waddington 1985:180–90).

Architecturally, the voluntary hospitals might have looked more familiar, but, of course, some of their buildings are still in use. Wards were large, rectangular rooms holding between fifteen and thirty patients in parallel rows of beds on each side. If you were to examine the patients, however, you might wonder how many of them were sufficiently ill to justify their place. People seldom died in the voluntary hospitals—death rates were probably no more than 10 per cent of admissions (Woodward 1974:123–42). This was achieved largely by refusing admission to people who appeared to be seriously ill or infectious. The typical patient would be more likely to be suffering some sort of minor surgical problem—a fracture, a skin ulcer, a fistula, or a boil. As a result, the whole atmosphere would have been more reminiscent of some kind of convalescent home. At the Royal Devon and Exeter Hospital, for example, patients were allowed to come and go as they pleased in the daytime until the 1830s, provided they did not return drunk. They were expected to help with the domestic chores, feeding the pigs, pumping water and serving meals (Hawker 1987).

To understand why patients were selected in this fashion, we must look at the way these hospitals were financed. Although there were some older institutions, like St Thomas’s and St Bartholomew’s Hospitals in London, which had substantial incomes from endowments, most of the newer foundations depended upon current subscriptions from well-off members of the community. Thus, it was not in the hospital’s interest that it acquired the reputation of being a place which killed people. Moreover, subscribers expected something in return for their donations. This might be preferential treatment in contracts to supply the hospital, for example, but more generally it was the right to nominate patients for a stay of six to eight weeks. These nominations would be considered at a weekly meeting of the governors which would then decide who was to be admitted, a policy that also tended to exclude acute patients.

Despite this charitable basis, the patients were no more likely to be very poor than they were to be very sick. Although the middle and upper classes made little use of any type of hospital until the twentieth century, voluntary hospital patients were likely to need sufficient resources or sponsorship to provide a deposit or guarantee against possible funeral expenses. In addition, there was often some admission charge. At Guy’s Hospital, London, patients in 1788 were expected to arrive

with a change of Body-Linen, Stockings, Neckcloth, Stock and Handkerchief, and to pay to the Sister Two Shillings and Ninepence for two Towels, a Tin pot, a Knife, a Spoon, an Earthen Plate and five Pairs of Sheets. (H.C.Cameron 1954 Mr. Guys Hospital 1726–1948. Quoted by Abel-Smith 1964:10)

Except for patients with venereal infections, however, actual subsistence and treatment would be free. Unfortunately, we know very little about who the patients were. Governors’ minute booksrecord discussions of the eligibility of domestic servants or apprentices of the subscribers, which may give us some clues. The issue there was whether an employer should pay for their care directly or whether the employer’s subscription should cover their hospital treatment. Given the importance of personal recommendation, though, it seems reasonable to suppose that most patients would have had some such connection, if not directly, then through friends or family members. Even so, there were not very many of them. In 1800, there were about 4,000 hospital beds in England and Wales, of which about 3,000 would have been occupied at any one time. That was one bed for every 5,000 persons (AbelSmith 1964:1).

What happened to everyone else? The answer seems to be that they remained in their own homes with the benefit of such medical attendance as they could afford and considered appropriate. Those who needed treatment and were unable to pay for it had to rely on the provisions of the Poor Law. This is the collective name for a series of acts of parliament dating back to Elizabeth I which required parish officers to levy property taxes to provide for orphans, the old, the mentally disordered, the unemployed, and the sick. This help took two forms: ‘outdoor’ relief which described services or money furnished to people in their homes and ‘indoor’ relief which would involve the person’s removal to a workhouse. In fact, there were relatively few workhouses built before 1834 so that most relief was provided on an outdoor basis (Henriques 1979:17–19).

Poor Law medical practice at this time has been depicted as a service provided by quacks or underpaid parish surgeons who were either so overloaded or so incompetent as to deny paupers adequate treatment, by the standards of the day (Hodgkinson 1967:8–9). More recently, however, Loudon (1987:228–48) has shown that this office was relatively prestigious and well-rewarded, with its holders being reimbursed on the basis of their private fees for each item of treatment. The competition to hold such posts was reflected in the high quality of care offered to acute cases. It is true that there was no legal restriction on who could be appointed as a parish surgeon until the 1860s, following the creation of the Medical Register and the statutory definition of the medical profession. But, as Loudon points out, the rapid mobilization of medical officers during the 1831–2 cholera epidemic certainly suggests that the parishes had a clear perception of who was and was not a competent practitioner, even in the absence of national standards. The negative picture may represent an over-reliance on writings by critics of the Poor Law as part of their campaign for change, although, as Loudon concedes, there is some evidence that the more restrictive attitudes which inspired the 1834 reform of the Poor Law (see pp. 11 and 30) were already leading to a deterioration in the service during the 1820s.

Nurses before nursing

This sketch of health care at the beginning of the nineteenth century will serve as a background for our discussion of the development of general nursing. The first difficulty we face, however, is in defining what counts as nursing so that we know what to include in our analysis. In the early nineteenth century nursing was not an identifiable and self-conscious occupation. Anybody could freely describe themselves as ‘a nurse’ and call what they did ‘nursing’ until the General Nursing Council Register became operational in 1923. Even since then it has continued to be difficult to draw a boundary between nursing and non-nursing work and to discriminate between those parts which are reserved for members of the occupation, those which are shared by members of other occupations, and those which may be done by anybody. Thus it is important to find a way of differentiating between ‘nursing work’ and ‘work done by nurses’.

The relationship between work and occupations is a topic which has long been of interest to sociologists. However, the main application of this interest to nursing has previously been confined to the question of whether it is or is not a profession. Although we shall not be pursuing that issue here, its prevalence obliges us to explain our decision.

The question about the status of nursing is particularly associated with what is known as the trait or attribute approach to the study of professions. This involves drawing up a list of criteria against which various occupations can be matched (e.g. Greenwood 1957). Those meeting all or most are accepted as professions, those meeting some criteria are often called semi-professions and those which meet few or none are ruled out of the category. This approach has, however, been effectively discredited by Millerson (1964) and Roth (1974) who have shown how vague and inconsistent these lists are and how they tend to be compiled to yield particular results. Moreover, this kind of classification ends up with very little positive to say about either the organization of work or the organization of society. It is largely a matter of ranking occupations on some sort of prestige scale. One way round this problem which was explored by some writers was a proposal to study professionalization as if it were an evolutionary process by which certain occupations enhanced their status (e.g. Caplow 1954, Wilensky 1964). But this also foundered on the problem of producing a usable definition of what a profession was, as the end-state of that process (Turner and Hodge 1970:23, Johnson 1972:31).

As Becker (1970) has pointed out, the fundamental problem is that the word ‘profession’ is used for two incompatible purposes. One is as a ‘folk concept’, a way in which anyone can describe a particular occupation or activity with respect: hence the ‘professional foul’ in soccer, for example (cf. Horobin 1983:84–95). In this sense it is a badge of honour which is tied to particular societies in a particular historical period (Freidson 1983:23–6). The other use is as a label for a group of occupations which form a meaningful unit for sociological analysis.

Various attempts were made during the 1970s to develop this latter approach. Freidson (1970a) suggested that the term should be defined in relation to occupations which had achieved ‘functional autonomy’, the ability to determine their own conditions of work, although he has subsequently rejected attempts to treat this as if it were an attribute and identify it with self-employment (Freidson 1986:123–5). Johnson (1972, 1977, 1982) has explored the ways in which professions could be delineated as occupations which stand in a particular relationship to the political structure of Western societies, while Larson (1977) has treated them as occupations which have established a distinctive measure of control over the market for their services.¹ Freidson (1986) has attempted to unite these lines of analysis by proposing that professions are intermediaries between bodies of formal knowledge and the human activities which apply them. This role is both a source of autonomy and a basis for economic, legal and political privilege.

While many of these ideas can be usefully employed in the analysis of nursing, their direct relevance is limited, as Freidson (1970b:20–2) observes, by the position of the occupation in a medically dominated division of labour. It therefore seems more helpful to start from the fundamental questions identified by Hughes (1971:283–417) and pursued in various ways by Freidson (1978), Dingwall (1983a, 1983b), and Abbott (1986). This would absorb the study of professions into a more general sociology of occupations. Rather than asking ‘What is a profession?’, we should be asking ‘What kinds of occupation are there and how do they divide the work that has to be done in a society?’ The division of the workforce into occupations creates a scheme for the social classification of work. There is no necessary relationship between the categories of this scheme, occupations, and the array of tasks that need to be done in a society. So we can ask why that array is carved up in one way or another at different times and in different places.

We can draw an analogy between the social organization of work and the development of a city. Think of all the work that has to be done in a society as the land on which the city is built. Now think of all the different occupations you can name as the buildings put on that land. But cities are not static. Their boundaries change. Redevelopment is occurring all the time. Some buildings are being improved and enlarged. Sometimes plots will be cleared and new constructions put up on them. In the same way, the definition of work is something which may change over time. New occupations may be created, like computer programmers in the 1950s. Others may disappear, like ostlers when the stage coach gave way to the steam train. Some occupations divide as surgeons did from barbers in the sixteenth century. Others fuse, as physicians, surgeons and apothecaries did in the mid-Victorian period.

One way of viewing the Nurses Registration Act 1919 is as a licence for a prominent group of people to redevelop an area of the city. But the possible form of the building they erected was partly determined by the nature of the site and the previous attempts to develop it. Some of these were incorporated in the new scheme and others excluded. A number were subsequently annexed, a move which was recognized finally by the Nurses, Midwives and Health Visitors Act 1979. This book is rather like an archaeological dig that attempts to trace the earlier foundations which run across the site and may divide it in a very different fashion.

It seems logical, then, to begin from the core activity of providing direct care for sick people and to trace the changes in its ownership and its association with other tasks such as the delivery of babies and the prevention or management of health-related problems.² What did the care of the sick consist of in the early nineteenth century and who gave it?

Then, as now, the greatest part of the care required by the sick involved some kind of assistance with activities of daily living that they were unable to carry out for themselves. Indeed, before the introduction of modern techniques of diagnosis, this would have been the main way of defining someone as ill, that they were involuntarily unable to look after their own bodily needs. Care at this level involves basic assistance with feeding, toileting or personal hygiene. At its margins this form of care would merge into two other types of involvement. One would be the simpletechniques of preindustrial medicine—diet, dressings, poultices, herbal infusions, etc.—and the other would be the spiritual care of the terminally sick or injured.

If we go back to the first half of the nineteenth century with this broad description of nursing care, we can identify four categories of people who are involved in its provision. The first, and almost certainly the largest, would have been members of the sick person’s household caring for them at home. Their informal work might have been assisted by one or other of two types of paid helper, which we shall describe as the ‘handywoman’ and the ‘private nurse’. Both of these groups were independent, self-employed workers and they can be distinguished mainly by whether they were providing a cheap service for the poor or a premium service for the better-off. Because their services were being traded, they can reasonably be regarded as part of the official workforce, although neither occupation is welldefined and the handywomen, in particular, may also have been involved in criminal work. There was some movement between domestic and institutional employment and the hospitals show a similar social division among their staff. We shall, then, organize our analysis around the work and the workers rather than their particular location. Almost all of these informal or official carers would have been women.

The fourth category of workers were all men. They were types of medical attendant—‘apothecaries’, ‘dressers’, ‘residents’, ‘clinical clerks’—whose memory is preserved only by job titles for junior staff in some rather traditional hospitals. Originally, these men would have been the subordinates or apprentices of more powerful or prestigious practitioners. They were the people who actually administered such routine treatments as were used in hospitals before the nineteenth century. Outside the hospital many of those same treatments would have been given by the other types of carer, either as directed by an adviser, who might or might not be a medical practitioner, or following traditional ideas, passed on by word of mouth or in books of home remedies.

Domestic nursing

It would now be impossible to quantify the division of nursing work between informal and official carers in pre-industrial England. On the basis of the surviving diaries and literary sources, however, it seems reasonable to infer that most care would have been given on a relatively informal basis by other members of the sick person’s household.

We would emphasize the contribution of the household rather than the family. There is a romantic view of the past which supposes that people tended to live from one generation to the next in the same house or neighbourhood in large and inter-related families. This gave communities a capacity to care for the sick which they are unable or unwilling to provide in our own time.

In fact, families of this type were relatively uncommon in England. Over the period 1622–1854, only 6 per cent of households contained three generations of kin: over 70 per cent consisted of two generations alone (Laslett 1983:98). Several factors are involved in this. First, the potential demands for care were more limited than in the twentieth century. For example, between 1539 and 1843, the proportion of the population over 60 never exceede’d 9.7 per cent, compared with 21 per cent in 1985 (Laslett 1983:111, Central Statistical Office 1987:Table 2.4). Second, the number of potential carers and the extent of their obligations was limited by the relatively small size of families and the high rate of marriages broken by death. Although an average woman was likely to have just under seven children, of whom three-quarters would survive infancy, the typical marriage only produced just over four. Between one-third and onehalf of all children lost one or both parents during their childhood, creating complex two-generation households of single parent families and families of orphans being brought up by remarried step parents (Hair 1982, Laslett 1983:113–19). Finally, even where carers were theoretically available, they were quite likely to have moved out of the locality. From the sixteenth century, and before, there is evidence of considerable population mobility (Clark 1979, Laslett 1983:75).

It is probably more important, then, to recognize the role of household servants. Although grand establishments were rare, most households were lik...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Acknowledgements
• Glossary of abbreviations
• Chapter one: Nurses and Servants
• Chapter two: The Revolution in Nursing
• Chapter three: The New Model Nurse
• Chapter four: Making the Myths
• Chapter five: The Search for Unity
• Chapter six: The Nationalization of Nursing
• Chapter seven: Mental Disorder and Mental Handicap
• Chapter eight: Midwifery
• Chapter nine: District Nursing and Health Visiting
• Chapter ten: Professional Autonomy and Economic Constraints
• Notes
• References