In 1860, the Nightingale School of Nursing opened at St Thomas's Hospital, London. Florence Nightingale's overriding raison d'etre in the setting up of this foundation was a replacement of the old fashioned nurse (caricatured by Mrs Gamp—an “ignorant and immoral drunkard”) by the highly trained, and eminently respectable “lady-nurse”. While this change met with a great deal of approval from the lay public and the majority of the nursing profession, a minority of the latter together with the bulk of medical practitioners (including several leading physicians and surgeons of the day) wholeheartedly opposed this revolutionary move. It was felt, by them, that the medical profession was in danger of losing control over nursing with the resultant sacrifice of satisfactory patient care. Today, both medical student and nurse training is moving noticeably away from the bedside, an orientation which has added such an important dimension to British medical/nurse training over so many generations. Is this 19th century experience yet another example of history repeating itself in the medical sphere?
- medical history
- Florence Nightingale
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Florence Nightingale (1820–1910) (fig 1)1,2 sought to improve the status and efficiency of the British nurse after her experiences in the Crimean War (1854–56).3,4 Previously there had been little or no formal training, and the end product (see below) was exemplified by Charles Dickens (1812–70) in Martin Chuzzlewit. Nightingale founded the first school of nursing (bearing her name) with backing from the Nightingale Fund, at St Thomas's Hospital in 1860.1,2 She realised, however, that for her “reforms” to be accepted, she must win over the confidence not only of the nursing but also the medical profession.5,6 Despite this, however, there remained many in both professions who were exceedingly dubious about this changing rôle of the nurse.7 The BMJ for example, considered early in 1880 that level headed thinking was required “ . . . unless we are to see the nurses, who are essentially the instruments of the doctor, become his mistresses”.8 This article cited a case in which a Manchester physician had been suspended for “a breach of discipline in interfering in an improper manner with the control of nurses by the lady-superintendent”; as a result, “ . . . various [Manchester] hospital physicians and surgeons [sensed] a tendency to make the nurses, not their aids, but their supervisors and superiors . . . the nurse must be a person who owes strict allegiance [to the physician], who pays blind obedience to his orders, and pays it as absolutely as a private soldier the command of his superior officer”. This writer also emphasised that “They [the physicians], and not the nurses, are responsible for the patients; and they have a right to insist peremptorily and absolutely that the nurses shall be disposed according to their wish, and that the nursing shall be carried out according to their orders and in the manner they think most likely to be conducive to the welfare of their patients”.
A NURSING VIEWPOINT
With these reactions in mind, Margaret Lonsdale9 initiated a correspondence in the prestigious and widely read journal The Nineteenth Century in 1880.10 She felt that “the medical profession [was attempting] to retain the old system of employing untrained nurses . . . instead of making use of the trained labour which is now at their disposal [the new system] . . . provided there was a nurse to look after their patients, they were simply uninterested in her up bringing, education, training or any other feature of her existence”. The senior medical staff were, in effect, satisfied with the status quo! Certain members opposed “with remarkable pertinacity the employment in their hospitals of the intelligent [our italics] class of trained women who [were] supporting the new system”; they were, in fact, supporters of the “old” system. She focused her detailed comments on Guy's Hospital (which was at that time undergoing significant nurse-doctor problems) and contrasted the “old” with the “new” system of nurse training. The “old” system (still apparently in operation at the London Hospital) drew women “mainly from the class to which the domestic charwoman belongs” and who are totally untrained. After about three months as a probationer or assistant nurse, “these women [are] promoted to the position of head nurse themselves [and put in charge of seriously ill patients] under the direct control of the `sister'; . . . the only time at which they could obtain air and exercise was [she wrote] after nightfall . . . when the old-fashioned head nurse went out to take her hardly earned holiday, too often alas! in the nearest public-house”. “I am far from saying [wrote Lonsdale] that every nurse . . . was drunken or dissolute, but I do say that, as a rule, their moral character was unsatisfactory . . .”. The average night nurse was “very aged and feeble, to say nothing of [being] hopelessly drunken . . .”. The wages of both day and night nurses ranged from 16 to 22l[£] per annum. Of the “new” system (then in operation at St Thomas's, King's College and Charing Cross Hospitals, and introduced the previous November into Guy's Hospital), Lonsdale had little to say in her article: “ . . .in these days, when nursing is rapidly becoming a fashionable mania, and books about the subject are widely read, the principles of modern nursing are pretty well known”. One to three years' probation was necessary (she considered) before a woman was qualified to be put in charge of any patient; “ . . .besides her dress given her, a uniform which she is required always to wear [so that] she may be recognised everywhere as belonging to the institution to which she is attached [she] has regular hours appointed to her . . . for air and exercise, and is rarely if ever allowed to leave the hospital after nightfall”. She followed this by defining the rôle of the sister. The matron, Lonsdale wrote “is the supreme authority with regard to the general rules of the nursing”. The “mere presence of [this] higher class of women as nurses” would also result (she claimed) in a moral restraint to the general behaviour of the junior medical staff and medical students (“who are, as a class, universally acknowledged to be uncouth”). She ended her article with a plea that nursing and medical schools should coexist side-by-side.
This article, not surprisingly, received coverage in the BMJ.11 While sympathising with her approach, that is that nurses should be properly trained under the new system, the writer of this article concluded: “The real question is, how and whence the trained material [that is the educated nurse] may be best obtained; how it may be utilised for the successful nursing of large institutions to which medical schools are attached”. “Able and scientific physicians and surgeons [the writer continued] should be at the helm in such matters; they ought to be the controllers, not controlled. . . .We venture to insist . . . that [nursing is not] an independent element of which [the medical man has] no knowledge . . . . Nursing is the first step in—often the most important, sometimes, indeed, the only—treatment; and a doctor is, or ought to be, a nurse before he is a physician”.
OPINION(S) FROM THE MEDICAL PROFESSION
Lonsdale's article brought forth a torrent of correspondence from several leading members of the medical profession in following issues of The Nineteenth Century.12 W W Gull, FRS (fig 2),13 agreed that the nurse selection process at Guy's had left a good deal to be desired, although nursing standards had not deteriorated to his knowledge in the previous 15 years; Lonsdale however, spoke with “a want of fairness and want of knowledge”; she had in fact over-stated her case, particularly with respect to the old regime, some of its members of which she considered were “generally immoral and intemperate”! These remarks were unjustified in someone with a “most limited and superficial experience of the system [having been] but a few weeks in the hospital as a learner of the rudiments of nursing”. She was in fact “a spokesman of the new [our italics] system”. Assuming Lonsdale's views represented those of the nursing profession overall there would now be a great deal of opposition to a nursing school being established at Guy's. “The [medical] profession can never [he considered] sanction a nursing system which claims for itself not to be under their control and direction”. Gull was also far from convinced that only women could make good nurses (although they possessed many desirable characteristics); “ . . . it would be an error to suppose [he wrote] that they have any special intellectual fitness for it”. Lonsdale (he claimed) had hinted “that nurses should have a right to exclude, except at certain times, medical students from the wards”! “Nothing could be more absurd than such a proposition”. Medical students should be encouraged to enter the wards at all times—day or night. “ . . . I had long hoped [he concluded] that our large hospitals might be made available for the education and training of carefully selected women for nurses . . . and whilst I have been encouraging the authorities at Guy's to prosecute this movement, comes this writer's article, like a dead fly in the ointment of the apothecary, and mars the work”.
Dr S O Habershon14(Senior Physician at Guy's)—who later that year was to deliver a controversial address on “nurses and nursing”15—as President of the Metropolitan Counties Branch of the BMA, not surprisingly (Lonsdale had served in his ward) joined the correspondence.12 “We live in a stirring age [he began], when women's rights and modern schools of thought are brought before us on every hand”. “ . . .there is such a thing as sentiment instead of judgment, and conceit favoured by ignorance”! “The [Guy's] Medical School [had without any doubt] added . . . to the fame and lustre of the hospital, and [had also] enabled it in a tenfold degree to relieve suffering and to save life”. He considered that Lonsdale's article had provided a “picture [which was] drawn from imagination”; it was virtually devoid of fact! The previous November “a new matron [Miss Margaret Elizabeth Burt, who served from 1879–82] with modern ideas [there had been zero consultation with the medical staff] was suddenly introduced into the hospital, whereby its peace and harmony were overturned as completely, as if an ignited bombshell were thrown in the midst of a zealous ambulance corps”. Under the new system, nurses were “rotated” every three months into a different ward (he abhorred the lack of continuity in patient management) in order for them to “learn nursing more fully . . .”. In Habershon's opinion this system failed to take account of “the comfort of the nurses and the benefit of the patients”; he was especially concerned with the impact of the new system on patient care. As a result, many nurses “who were valuable [and] efficient” had left; in one day, he maintained, 24 who were far from being “drunken, immoral, [and] untrained”, had departed Guy's and headed for alternative institutions. It was not generally known (he maintained) that “Guy's Hospital [had] been one of the largest institutions for training nurses, [as well as being] the first . . . For fifteen years the nurses associated with the Rev. Mr. Pennefather's work at Mildmay have received a similar benefit, and for ten years Mrs. Ranyard's Bible nurses [“devoted Christian women, true sisters of mercy”] have shared in a like training”. Habershon too was incensed at the relative detachment of the new nursing system from the jurisdiction of the physicians; nurses (he claimed) “can only accomplish the object they have in view [in “relieving the sick and suffering”] when under the guidance of medical skill”. “Should the fashionable mania for nursing have full sway according to the theories of Miss Lonsdale [he proclaimed], the physician himself would be scarcely required”. “ . . . if the hospital is to be continued as an institution for the skilful treatment of disease, it must be under the direction of the doctors, instead of the matron, in all things that concern the patients”. He concluded: “ . . . the ward system has worked well hitherto, and a ruthless interference with it will prove a great misfortune”. “The time may come [he ended his diatribe] when it will be found that long experience and professional science are more valuable than sentimental theories”.
The third “opponent” of the Nightingale system was A G Henriques16 from the London Hospital.12 Trained nurses, who preferably should also be well educated, were far preferable to untrained ones, he considered. Lonsdale had, however, introduced a number of “damaging and incorrect statements” into her article. “ . . . the old system (of nursing) [was, Lonsdale had claimed] still in full force” at the largest institution of its kind in Britain—the London Hospital and “she then proceeds [he continued] to condemn . . . the old system of nursing”. Such a statement, as well as being inconsistent “may possibly damage [that] hospital in the eyes of the charitable public”. The “comparative merits of nurses connected with sisterhoods and nurses free from the obligations of sisterhoods [had] recently been very warmly discussed”; the London Hospital's management had come firmly down on the side of the latter! It was in any case, he wrote, “wiser . . . to introduce reforms gradually and unostentatiously . . .”.
THE CONTROVERSY ESCALATES
Lonsdale's article drew further attention in the columns of the BMJ.17–19 A surgeon at the Manchester Royal Infirmary considered, that her essay possessed two major themes17: (i) that the “old style” nurse was “an ignorant and immoral drunkard”, but was the preferred option (compared with the “highly trained lady-nurse”) in the eyes of the Guy's medical staff, and (ii) whether or not nurses should have their own “government”—fully detached from the jurisdiction of the medical staff. Both were over statements. The second contributor was an “old type” nurse (“a gentlewoman trained in nursing”) who had worked at Guy's as an Honorary Sister (a “lady-nurse”)18; she felt that Lonsdale was “utterly unfair” to the “old type” of nurse, especially with regard to sister/medical student relationships. A third article (written anonymously) summarised the correspondence to date,19 which included an article by Walter Moxon (1836–86) (also a physician at Guy's ) in the Contemporary Review, in which he highlighted the “hysterico-malignant ravings of the young writer [that is Lonsdale]”. He compared her essay with another she had recently written—Sister Dora, a biography (1880)—about which a reviewer in the Saturday Review was “in doubt as to the accuracy of some of the almost miraculous feats attributed by our young authoress to Sister Dora”!
The next (June) issue of The Nineteenth Century contained a further two contributions from leading members of the medical profession.20 Octavius Sturges (1833–94)21 of the Westminster Hospital focused on similar difficulties (presumably an indirect result of the Nightingale reforms) at other major London hospitals.20 Lonsdale's article was he felt, “an indictment of the medical profession in respect of its attitude towards skilled nursing”; it suggested that (i) “doctors are poor judges of the quality of nursing”, and (ii) “they prefer bad nursing to good”. “ . . . in the history of nursing reform during the last twenty years [he continued] the hearty co-operation of the medical element in our great metropolitan hospitals has been conspicuous”; doctors were, in fact, “on the side of good nursing”. Lonsdale's remarks were wide of the mark! In any final analysis, the nurse and doctor can be shown to possess different roles; however, the ultimate responsibility must surely rest with the latter! But the “strict line of demarcation [was he felt] unfair and unnecessary”, largely because women could (in the late 19th century) pursue a career in “nursing” or “medicine”—for example, at the “School of Medicine for Women lately established in London”. “The more experienced and accomplished nurses might well occupy the position once assigned to the apothecary of the [18th] century”. Sturges concluded his article: “I am persuaded . . . that any suggestions which might be made for the improvement of the nursing system, or the fuller recognition of nursing as part and parcel of scientific medicine, would be readily and respectfully considered”. He was, he said, certain that not only at Guy's but everywhere else as well “ . . . physicians and surgeons will decline to undertake the care of the sick where there is divided rule and joint responsibility”.
The young Dr (later Sir) Seymour Sharkey (fig 3)22 of St Thomas's Hospital pointed to the fact that the “nursing of the present day is very different from that of the past”20; the Mrs Gamps of the past had been replaced by “young and intelligent women of a better class . . .”. “Where stagnation once reigned supreme [he continued] all is now life and activity”. He did not wish “to do the least injustice to the impulse given to scientific [our italics] nursing by such women as Miss Nightingale”. “Ladies . . . now offer themselves in such overwhelming numbers that the supply is far greater than the demand” since nursing is “a very important part, of medical treatment”. “It must [he wrote] be detrimental to the patients that control over the nursing department should pass entirely out of the hands of doctors”. “Ladies must not suppose that it is necessary or even desirable that the business of nursing should become obsolete among women in a lower scale of social life . . . A judicious mixture of the two is what is wanted”! Sharkey outlined the varying responsibilities of the sister (who must possess “intellectual power”), over the staff nurses and the “under-nurses”. He was also in favour of large hospitals possessing nursing, as well as medical schools. However, a nursing school “can only be tolerated in a general hospital if the number of women being trained is comparatively small . . .”. An essential question (was, he continued)—“Should a hospital train just so many first-rate nurses as it requires for its own purposes . . . or should it allow the foundation of a nursing establishment within its walls” which educates numbers of others “from whom the hospital receives but little benefit?” He concluded: “Let ladies who wish to be doctors as well as nurses train themselves in an appropriate medical school [as recommended by Sturges], and leave the humbler but no less honourable profession of nursing to those who have the common sense to see that the training of a nursing institution can never make them properly qualified medical practitioners”.
The correspondence in the June issue was completed by a follow up article from Lonsdale.20 This was an apologetic and “low key” affair. At all times, she wrote “a doctor [is] the master and controller of both nurse and patient”. She highlighted the difference(s) between the responsibilities of the nurse and the doctor: “as a nurse advances in the scientific knowledge incidental to her calling, she declines in efficiency as to the minor and more drudging details of which . . . the life of a nurse is greatly made up”. Lonsdale also dwelt on “the so-called religious organisation which the modern nurse is supposed to be anxious surreptitiously to introduce into our old-established hospitals”. It is “impossible to deny [she continued] that some of the best and most successful efforts in the way of hospital reform have been made by nurses belonging to Sisterhoods of all types”. She concluded by emphasising a need for close working relationships between doctor and nurse, which were she considered, essential in the interests of the patient.
THE CONTROVERSY CONTINUES UNABATED
Also in June 1880 the BMJ published an account of the 20th “annual assemblage” of the St Thomas's Hospital “pupil nurses” (35 in number)23; this nursing occasion was attended by several physicians and surgeons. John Bristowe, FRS (fig 4)24 paid tribute to the nursing of the hospital—under the matron, Mrs Sarah Wardroper,25 and the Treasurer “bore testimony to the advantage that the hospital derived from the [Nightingale] school”. Since its foundation at the old hospital (in the Borough), 565 candidates had been admitted, and 362 probationer nurses had left the school as certified nurses after completion of one year's training.26 Henry (later Sir Henry) Burdett (1847–1920)27,28; one of the greatest figures in the history of nursing, also wrote to the Lancet on the Dispute at Guy's Hospital29; having recently been misquoted in that journal, he emphasised that he was totally opposed to “female quacks”, and wholeheartedly supported trained women as nurses.
Simultaneously, the Lancet drew attention to two recently published articles,30 which the anonymous writer welcomed because they were written in protest against “that hysterical sentimentalism which is being introduced into the practice of nursing in certain hospitals and institutions”. The writer considered that both old and new systems had their flaws. The new system—which should be followed—was to be “found in the wards of St Thomas's Hospital, and in the work of the Nightingale Fund”. Some five months later, the same journal carried a leading article on nurse training31; the “sole qualifications required for tending the sick [the anonymous writer considered] 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 writer continued], the nurse ought to be the servant of the doctor, and should carry out his instructions”. “The `sisterhoods' [the writer continued] are . . . organisations for the propagation of special religious views . . . to extend the influence of particular ecclesiastical schools and systems. The sick chamber seems to them a `field' or `vineyard' for this work”. This writer also favoured the employment of male nurses under certain circumstances; “It is a mistake to suppose that women are necessarily the only good nurses . . . . If the employment of men to nurse men were encouraged a great difficulty would be surmounted, and a good social reform begun”.
LATER REACTIONS TO THE NIGHTINGALE SYSTEM OF NURSE TRAINING
Almost two decades later Lady Eliza Priestley,32 then an eminent writer on health and sanitation, wrote a review of the on-going problems facing nurses and nursing, also for The Nineteenth Century.33 “At the beginning of the Christian era [she wrote], and also in the Middle Ages, tending the sick was regarded entirely as a religious duty . . .”. In all Roman Catholic, unlike Protestant, countries when a sick-nurse is required “it is difficult to find one outside the walls of a religious institution”. Until recently, nursing of the sick by women in their own household was the norm; now, “nursing as an art has emerged . . . and duty into a science [our italics] to meet the general advance of our times”. The duties of a nurse in a Protestant country (she continued) “are no less serious . . . than they are in those countries where the `Sisters' are celibates [having taken] the vows of chastity and obedience, with the one great objective before them, the Cross of Jesus Christ”. With British nurses (or “sisters”) “There is not the same respect for privacy, silence, obedience, and even the discipline which was so marked a feature under the régime of Florence Nightingale”. The class from which nurses came, and their social status, had changed enormously, she maintained; furthermore, “after the prescribed three or four years' training [the nurse was] pronounced competent to attend the sick in all the various and varying circumstances of life, in every kind of home”. Priestley then discussed the vulnerability of female nurses who cared for male patients without a chaperon, and she referred to the title given to the “new” profession: “The new road to matrimony” or (according to the St James Gazette) “To the altar by the new cut”. “It is strange [she continued], considering the manifold requirements of life, that so little is done to encourage the training of male nurses [who were acceptable in mental asylums and in military and naval hospitals] for domestic employment”. She also referred to the fact that some nurses felt (after their long and arduous training) that they knew at least as much as the doctor; it is not unknown that “nurses have occasionally been dismissed for assuming that they were in charge of the case, instead of being in charge of the doctor's patient”. She referred also to the fact that “lady doctors [experienced difficulty] in getting modern trained nurses [of the new system] to act under them at all!” Lady Priestley subscribed to the view that “one year's training and six months' district work, as with the Queen's Jubilee nurses [who served the district and rural poor], would [be sufficient in length]”. She concluded by suggesting a reduction of “the immense gap . . . between the humble celibate of Roman Catholicism and the accomplished, and often flippant, woman of modern times”. Highly trained nurses (that is products of the new system) should ideally be confined to a few highly specialised areas!
In the following issue of this journal, Ethel Gordon (Mrs Bedford Fenwick)34 replied to Priestley's “paradoxical and illogical” article: “Some of its statements and most of its conclusions [she considered were] inaccurate35; and yet its premisses [were] for the most part correct”. Fenwick was highly critical of her use of the terms “flippant”, “frivolous”, and “flighty”. The present religious basis for nursing had been underrated by Priestley! From her experience, she felt that many nurses were in fact entering the profession from a “heartfelt desire to fulfil the Divine command to tend the sick”. She considered incidently, that . . . “in innumerable instances the thick and seldom sanitary material of the saintly garb [of the Fille-Dieu referred to by Priestley] must have conveyed the germs of disease and death . . .”. Fenwick was emphatic that three years of training was an essential prerequisite for registration and the fact that young women entered (and withstood) this period of rigid lifestyle, together with the low rate(s) of pay, was in itself proof of dedication. It is (she felt) “of the greatest importance for the public that nursing has `emerged into a science [our italics]' ”. “Sairey Gamp could neither comprehend, nor could she be trusted to execute, instructions involving the use of the thermometer and other instruments [or], the administration . . . of stimulants”. In fact, with the current developments in medical science, it was crucially important that “nurse training” should not be left behind! The “well trained nurse” was essential! “For some years [Fenwick claimed] the leading nurses have been striving to protect their profession against the very women [untrained nurses] whom Lady Priestley has described, and who, they know well, are not trained nurses at all”. Such a class of women, “are dangerous to the sick”. She continued: “ . . . the inability to discriminate between trained and untrained nurses is a matter of grave public concern”. Nine years previously, Fenwick wrote “The Royal British Nurses' Association was formed to cope with the evil”; and to compile a Register of Trained Nurses (who had completed three years training in hospitals). Although there was great awareness of this scheme, “there are [she maintained] many medical men at the present day [who] only employ registered [our italics] nurses . . . There are unhappily [on the other hand] others who do not yet recognise the importance of having their subordinates under the professional control which a system of registration affords . . .”. “The suggestion which is strongly advocated [she concluded] is that an Act of Parliament should be passed forming a Nursing Council composed of [both] medical men and trained nurses”.
Nightingale made a major contribution to nurse training in 1860 (she seems, however, to have been far more interested in sanitation, hygiene, and hospital design36), but her reforms were not immediately accepted by many contemporary physicians and surgeons, or by a minority of nurses. They were, in the main, not dissatisfied with the status quo, and were obviously somewhat apprehensive concerning the major changes being introduced by Nightingale. Indeed, they were fearful that the nursing profession, with its envisaged scientific professionalism, was becoming a serious threat to patient management. Although Guy's Hospital was the focal point, the controversy escalated throughout the country.
From time immemorial, young women have become bedside nurses because they felt it a duty and a privilege to care for the sick and dying (see above); in fact it has always been a vocation. Competence of a nurse to practise has traditionally been complex and has involved: (i) personal moral characteristics, (ii) technical knowledge, combined with practical skill, (iii) a major contribution from the ward sister (the “trainer”), and (iv) professional etiquette involving appropriate relationships with medical and nursing staff, but above all patients.37 This in fact, has been a profession (like that of medicine) based largely on apprenticeship. But that has recently changed; so what precisely is the rôle and purpose of the modern (professional) nurse? Fears that modern nurse training was becoming increasingly detached from traditional values, must have been dominant in the minds of those who opposed the likes of Lonsdale more than 100 years ago; it is no exaggeration to emphasise that these same anxieties are recapitulated in the minds of some doctors and certain sections of the nursing profession today!
As healthcare assistants have subsumed much of the nurses' personal workload, confusion and paradox surrounds the identity of modern nurses. It is important therefore that the controversy (at times acrimonious) outlined in this paper is taken into account in the present day. Although nurses' salaries still leave much to be desired, an escalating academic (scientific) dimension in place of traditional clinical care has come to dominate nurse training; this is also a significant factor in driving away much suitable material! Present day medical student training is also largely detached from a clinical scenario. The nurses and doctors of the future will, if current trends continue, lack many of the clinical skills (which have added such an important dimension to British medicine and nursing) of past generations. History does indeed repeat itself in medicine (and nursing)!38
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