Who cared for the carers?: A history of the occupational health of nurses, 1880–1948 9781526102843

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Who cared for the carers? A history of the occupational health of nurses, 1880–1948

PALMER

Today, high rates of sickness absence in the nursing profession attract increasing criticism. Nurses took more days off sick in 2011 than private sector employees and most other groups of public sector workers. This book argues that the roots of today’s problems are embedded in the ways nurses were managed in the late nineteenth and early twentieth centuries. It documents the nature of nurses’ health problems, the ways in which these problems were perceived and how government, nurse organisations, trade unions and hospitals responded. It offers insights not only into the history of women’s work but also the history of disease and the ways changing scientific knowledge shaped the management of nurses’ health. Its inclusion of male nurses and asylum nursing alongside female voluntary hospital nurses sheds new light on the key themes of interest to historians today, particularly social class, gender and the issue of professionalisation. It will interest those studying nursing, the history of medicine and the history of occupational health, as well as gender studies.

Who cared for the carers?

T

his book compares the histories of psychiatric and voluntary hospital nurses’ health, from the rise of the professional nurse in 1880 to the advent of the National Health Service in 1948. In the process it reveals the ways national ideas about the organisation of nursing impacted on the lives of ordinary nurses. It explains why the management of nurses’ health changed over time and between places, and sets these changes within a wider context of social, political and economic history.

Debbie Palmer is Associate Lecturer in Medical History at the Centre for Medical History, University of Exeter

DEB B IE PALMER www.manchesteruniversitypress.co.uk

Palmer ppc.indd 1

29/11/2013 21:59

Who cared for the carers?

This series provides an outlet for the publication of rigorous academic texts in the two closely related disciplines of Nursing History and Nursing Humanities, drawing upon both the ­intellectual rigour of the humanities and the practice-based, real-world emphasis of clinical and professional nursing.  At the intersection of Medical History, Women’s History and Social History, Nursing History remains a thriving and dynamic area of study with its own claims to disciplinary distinction. The broader discipline of Medical Humanities is of rapidly growing significance within academia globally, and this series aims to encourage strong scholarship in the burgeoning area of Nursing Humanities more generally. Such developments are timely, as the nursing profession expands and generates a stronger disciplinary axis. The MUP Nursing History and Humanities series provides a forum within which practitioners and humanists may offer new findings and insights. The international scope of the series is broad, embracing all historical periods and including both detailed empirical studies and wider perspectives on the cultures of nursing.

WHO CARED FOR THE CARERS? A history of the occupational health of nurses, 1880–1948 DEBBIE PALMER

Manchester University Press Manchester and New York

distributed in the United States exclusively by Palgrave Macmillan

Copyright © Debbie Palmer 2014 The right of Debbie Palmer to be identified as the author of this work has been asserted by her in accordance with the Copyright, Designs and Patents Act 1988. Published by Manchester University Press Oxford Road, Manchester M13 9NR, UK and Room 400, 175 Fifth Avenue, New York, NY 10010, USA www.manchesteruniversitypress.co.uk Distributed in the United States exclusively by Palgrave Macmillan175 Fifth Avenue, New York, NY 10010, USA Distributed in Canada exclusively by UBC Press, University of British Columbia, 2029 West Mall, Vancouver, BC, Canada V6T 1Z2 British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data applied for

ISBN  978 0 7190 9087 5  hardback First published 2014 The publisher has no responsibility for the persistence or accuracy of URLs for any external or third-party internet websites referred to in this book, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate.

Typeset by Servis Filmsetting Ltd, Stockport, Cheshire

For my husband, Jamie, my parents, Wendy and Keith, and my ­children Jack, Harriet, Charlie and Lucy

Contents

Acknowledgementsix List of abbreviations xi Introduction1 1 ‘To help a million sick, you must kill a few nurses’: the impact of the campaign for professional status on nurses’ health, 1890–1914 11 2 The First World War and nurses’ choice of occupational representation45 3 The Nurses’ Registration Act, 1919 71 4 ‘The disease which is most feared’: the problem of tuberculosis and its threat to nurses’ health, 1880–1950 99 5 Industrial psychology’s influence on the recruitment and welfare of general and mental nurses, 1930–48 128 6 Conclusion 159 Select bibliography 169 Index183

vii

Acknowledgements

I would like to thank the Wellcome Trust for funding my PhD research on which the book is based. I am tremendously grateful to Professor Jo Melling for his comments as my doctoral supervisor and Professor Mark Jackson for his generous advice and support. I would also like to thank archivists Jonathan Evans at The Royal London Hospital and Ann Morgan at the Plymouth and West Devon Record Office for their invaluable help particularly at the start of the project. I have received a huge amount of support and help from family, friends and colleagues but would especially like to thank Dr Ali Haggett and Dr Sarah Hayes for their friendship over the years. Finally, I owe my biggest thanks to my husband, Jamie, who has retained enormous and unswerving faith in me.

ix

List of abbreviations

AJN American Journal of Nursing AWA Asylum Workers’ Association BCG Bacillus Calmette-­Guerin vaccine BJN British Journal of Nursing BMA British Medical Association BMJ British Medical Journal BNA British Nurses’ Association CLA Cornwall Lunatic Asylum CMH Cornwall Mental Hospital CRO Cornwall Record Office HIV Human immunodeficiency virus HMWC Health of Munitions Workers Committee IHRB Industrial Health Research Board IIAC Industrial Injuries Advisory Council MPA Medico-­Psychological Association MRSA Methicillin resistant staphylococcus aureus NAWU National Asylum Workers’ Union NCW National Council of Women NHS National Health Service NUWW National Union of Women Workers PRO Public Record Office, London PUTN Professional Union of Trained Nurses PWDRO Plymouth and West Devon Record Office RBNA Royal British Nurses’ Association RCN Royal College of Nursing

xi

List of abbreviations RLH Royal London Hospital SDEC South Devon and East Cornwall Hospital TB Tuberculosis VADs Voluntary aid detachment nurses

xii

Introduction

In 1890, the Pall Mall Gazette argued that ‘to help a million sick, you must kill a few nurses’. The deaths of eight nurses from The London Hospital over the preceding two years were confirmation, according to the Gazette, that illness was an inevitable consequence of nursing in the late nineteenth century. ‘Are nurses sweated?’ the newspaper enquired and, in response, nurses described the ­detrimental effects on health of long working hours, poor diet and high patient-­to-­nurse ratios.1 However, the cause of the rising mortality rate, the Gazette concluded, was as much about the way nursing was managed as it was about poor work conditions: nurses were dying because there was something wrong with The London Hospital’s ‘administration’.2 The newspaper raised an important question that shapes the focus of this book: how did the management of nurses between 1890 and 1948 shape nurses’ experience of ill-­health? To answer this question, this book compares the histories of psychiatric and voluntary hospital nurses’ health from the rise of  the professional nurse in 1880 to the advent of the National Health Service (NHS) in 1948. In the process, it reveals the ways in which national ideas about the organisation of nursing impacted on the lives of ordinary nurses. It explains why the management of nurses’ health changed over time and between places and sets these changes within a wider context of social, political and economic history. The purpose of the introductory chapter is, firstly, to establish why this question is important and, secondly, to set out the analytical themes that ­underpin its subsequent discussion. 1

Who cared for the carers?

Managing nurses’ health today The management of nurses’ sickness has recently been targeted as a crucial way in which NHS trusts can save money. The cost of sickness absence nationally for nurses and health care assistants is approximately £141 million and rising. Since 2007, the amount the average NHS trust spends on agency staff to cover sickness has risen from 2.9 per cent of its staffing budget to 5.1 per cent.3 To tackle the problem, the Department of Health commissioned an independent review of the health and wellbeing of NHS staff in 2009, led by Dr Steve Boorman.4 The review found that the direct cost of all NHS staff sickness absence is £1.7 billion, and recommended a target decrease of £555 million. ‘Now is the time’, it advised NHS trusts, ‘to make your workforce’s health and wellbeing a priority so you meet your financial targets and improve patient care.’5 The management of nurses’ health care has become part of trusts’ business strategies to meet targets and measures set out by the government against which they are publicly measured. Such an approach is justified, according to the Boorman review, by the ‘clear relationship’ between measurable outcomes such as patient satisfaction, absence rates, agency spend, the number of MRSA cases, patient mortality rates and staff health. This new financial focus on the care of the health of nurses emphasises the need for managers to understand the links between health and organisational performance and, as a result, to remodel their provision of occupational welfare to include a much stronger preventative emphasis than in the past. Nurses, and other NHS employees, are to be supported to reduce their risk factor of disease by, for example, losing weight, increasing exercise and stopping smoking.6 Managers have also been advised to give a much higher priority to mental health issues and to tackle stress, bullying, harassment and the deep-­seated culture of long working hours. The Boorman review sets out a number of models of ideal mental health care including Tower Hamlets Primary Care Trust’s policy which trains managers to deal with staff’s mental health and Addenbrooke’s Hospital’s ‘Life’ scheme which offers staff poetry and painting competitions, book clubs, manicures and back massage.7 High rates of sickness absence in the nursing profession attract increasing criticism. Nurses take more days off sick than private 2

Introduction

sector employees and most other groups of public sector workers.8 The average rate of employee sickness in Britain is 3.64 per cent with teachers (4.6 per cent)9 and social workers (4.94 per cent) rates higher.10 Nursing staff had the third highest sickness rates (5.21 per cent) in the NHS between 2009 and 2011, with health care assistants and support staff ranked top (6.46 per cent) and medical and dental staff bottom (1.26 per cent).11 (Rates have been calculated by dividing the full-­time equivalent number of days side by the full-­time number of days available.) Nurses face a high risk of physical illness from the basic tasks of the job (such as lifting or exposure to body fluids), infection or, increasingly, from violence especially in accident and emergency departments and psychiatric wards.12 They are also vulnerable to mental illness, stress and suicide.13 There is no statutory NHS occupational health service and wide variations occur in the quality of care offered. NHS trusts generally are not giving priority to staff health, the Boorman report concluded, with many displaying behaviours ‘incompatible’ with high-­quality health services. Staff health is not seen as a priority at either organisational or management level.14 The drive for change, to raise the importance attached to staff health, may be better understood by informed comparisons with the past. Intentions At the centre of this book is an exploration of the management of nurses’ health in the first half of the twentieth century. It asks: who was responsible for nurses’ health and why did this change over time and between places? Today, the trend is for government policy makers to set national policy, which is implemented by health service managers. But what parts have hospital managers, doctors and nurses played in the past? The ability to influence policy entails significant power and, thus, the theme of power underpins this history of nurses’ health. This book is also concerned with how occupational health policy and practice varied between different types of hospital and between different groups of nurses. Its focus is limited to unpicking the differences between the voluntary hospital and the psychiatric hospital and does not cover, for example, the expanding and lower-­grade 3

Who cared for the carers?

hospitals in the Poor Law system. The decision to restrict its remit was made on the grounds that the significant disparity between asylum and voluntary hospital nurses regarding social class, gender and training produced very different systems of occupational care that warranted careful consideration. Some of the most important differences include the fact that asylums employed an almost equal number of men and women from working-­class backgrounds compared to the all-­female nursing staffs of voluntary hospitals who were drawn from more diverse social backgrounds. Furthermore, whilst voluntary hospital nursing was classed as women’s work in the late nineteenth and early twentieth centuries, looking after the male insane was regarded as men’s work despite the equal ratio of male to female nurses.15 Another significant difference concerns formal nurse training which was introduced in the 1880s to the voluntary hospitals studied and over thirty years later to the Cornwall Lunatic Asylum (1918). Asylum and voluntary hospital nurses’ choice of occupational representation also differed, with the former group selecting trade unionism and the latter the College of Nursing. Moreover, asylums were subject to a different legislative framework from that of the voluntary hospitals, and this inevitably produced a distinctive culture. The themes of social class and gender frame the book’s examination of nurses’ health. One of its aims is to trace the shifting cultural meanings of social class across time and assess the impact of change on the construction of nurses’ health. Social class, according to Barbara Harrison, explains why some groups of women workers and not others were subject to state intervention in the regulation of work between 1880 and 1914. She argues that intervention was often made on the grounds that there were peculiar problems resulting from women’s work, particularly the neglect of domestic and maternal duties.16 Such ideas carried currency in a climate of debates about infant mortality and industrial efficiency. Anxiety about a declining birth rate and concern about the health of the working classes, based on Britain’s need for a fit, imperial race, not only placed great emphasis on women’s reproductive ability but reinforced the idea that employed mothers were failures for being in paid work. For example, working-­class women formed most of the cotton industry labour force and enjoyed a reputation for independence, a counterweight in 4

Introduction

a period when a woman’s place was defined by an ideology of domesticity. This reputation was a problem for some medical officers who criticised female cotton workers’ alleged immorality outside work in debates about the health risks of ‘shuttle kissing’.17 In the late nineteenth century, nursing was emerging as one of the new ‘professional’ occupations for middle-­class women, Harrison suggests, and escaped state regulation because ‘it seems that middle-­ class women’s work in particular was rarely considered to pose occupational health problems or to require intervention’.18 Harrison’s contention that class explains the regulation of women’s work is important to this book because it prompted my initial interest in explaining the relationship between the image of nursing and attitudes to occupational health. Indeed, it raises one of its key questions: what part did the notion of class play in the professionalisation of nursing and how did it shape attitudes to nurses’ health? As time went on and nursing faced recurrent recruitment problems, how did the changing image of nursing affect attitudes towards nurses’ health? Gender is another crucial theme and, like the concept of social class,  is key to understanding how the health of nurses was constituted and represented. The central question raised is concerned with how the changing concept of gender, between 1890 and 1948, shaped understandings of nurses’ health. The period witnessed significant social and cultural change for women including widening educational and employment opportunities plus enfranchisement in 1918 and 1928. But, according to Patricia D’Antonio, the notion of gender ultimately constrained nurses’ opportunities. She argues that late nineteenth-­ century nurse leaders’ embracement of the gendered meaning of nursing – the notion that the ideal nurse was domesticated, maternal and thus qualified to care – initially allowed nurses to step out of ‘or perhaps more importantly up from the traditional ­conventions of their particular starting place’ but also ‘created boundaries that were often simultaneously both a source of strength and a dam around their ambition’.19 This book argues that occupational health was such a boundary: to ignore the hazards of nursing was initially a source of pretended strength but the extent to which this strategy limited the development of a comprehensive ­occupational health service for nurses needs addressing. 5

Who cared for the carers?

Structure and sources To assess how nurses’ health was managed, this book adopts a two-­ tiered approach. Firstly, it uses government-­sponsored reports and nursing and medical inquiries into the organisation of nursing to provide an overarching political framework. Although reports were often initiated in response to political problems such as a shortage of nurses, the restructuring of the health service or a need to manage manpower in response to war, solutions increasingly involved nurses’ health. Secondly, in order to place the individual nurse’s experience of illness within this context of political reform, the book focuses on primary sources drawn from the archives of The London Hospital, a large metropolitan teaching hospital, the South Devon and East Cornwall Hospital (SDEC), a smaller provincial voluntary hospital, and the Cornwall Lunatic Asylum (CLA), a large rural asylum. There are several reasons why these hospitals were chosen but most importantly they allow me to contrast the individual asylum nurse’s experience of illness with that of his or her voluntary hospital counterpart and explain how and why that experience changed over time. Furthermore, because the matrons employed at these three institutions held different political opinions about the professionalisation of nursing, it is possible to trace the relationship between matrons’ politics and occupational health policy. Chapter 1 examines the impact of the late nineteenth-­century debate about nurse registration on ideas about the health of nurses. Between 1888 and 1890, the mortality and morbidity rates among The London Hospital nurses dramatically increased and critics alleged that its cause was linked to matron Eva Luckes’s increasing power and political opposition to nurse registration. Using evidence from the inquiry called to investigate the problem, this chapter contrasts Luckes’s ideology about the organisation of nursing and the care of sick nurses with that of Harriet Hopkins, matron of the SDEC and a staunch supporter of nurse registration. The disparity between these women’s ideas is then contrasted with those of the CLA matrons who expressed no interest in the politics of nursing and enjoyed little power. Another reason for my choice of case study institutions is to explore the relationship between nurses’ choice of occupational representation and their health care. Chapter 2 explains why CLA nurses 6

Introduction

chose to join a trade union and take strike action in 1918, at the end of the First World War, by relating their choice of occupational representation to the terrible deterioration in their health and working conditions. Indeed, seven CLA nurses died from infectious diseases in 1917 and 1918, all under the age of thirty. The chapter compares the impact of the war on nurses’ health at the SDEC and examines whether these voluntary hospital nurses’ lack of interest in any form of occupational representation can be explained by the fact that they experienced little day-­to-­day change between 1914 and 1918. Brian Abel-­Smith and Christopher Hart locate the reason for voluntary hospital nurses’ choice of the College of Nursing and asylum nurses’ decision to join trade unions within a framework of gender and class.20 This chapter assesses how influential these factors were at the SDEC and CLA and suggests that further analysis must include nurses’ occupational health issues. The theme of the professionalisation of nursing and its impact on health is continued in Chapter 3, which examines the Nurses’ Registration Act of 1919. This is an important episode in the history of the health of nurses because it was an opportunity for state legislation to regulate nurses’ work conditions. Early twentieth-­century nurse leaders predicted that they would be able to stipulate conditions once professional status had been achieved. They reasoned that if nurses were better educated and more highly trained then improvements to economic conditions would follow. Yet their prediction failed to materialise, and although asylum nurses achieved standardised work conditions by 1919, voluntary hospital nurses’ work remained unregulated despite the award of professional status. This chapter questions why nurse organisations failed to achieve improvements revealing their attitudes towards the regulation of work conditions and the treatment of nurses’ health. The focus of Chapter 4 shifts away from the professionalisation of nursing to examine the rising incidence of tuberculosis (TB) among nurses in the 1930s and 1940s. Such was the attention given to the problem by nursing and medical journals that TB was presented as the only occupational health problem nurses faced in the interwar period. Why, this chapter asks, did TB emerge as a health problem for nurses at this point in time and not before? Furthermore, it also investigates how the changing conception of TB as a disease, between 7

Who cared for the carers?

1890 and 1948, impacted on ideas about nurses’ susceptibility. Despite Koch’s discovery in 1882 that TB was an infectious disease, explanations of risk continued to suggest a range of social factors particularly social class and gender. This chapter questions whether the different class backgrounds of nurses at the case study institutions shaped the incidence of TB. It also identifies why nurses’ experience of TB varied between places and across time. One reason the problem of TB was so widely discussed was the publicity given to recurrent recruitment problems. Outdated styles of discipline and bullying, critics alleged, were the main causes. Proposals for a radical reorganisation of nursing using industrial psychology as a template began to gain credibility. Psychological ideas, Chapter 5 argues, became increasingly influential as recruitment problems intensified during the Second World War. This chapter assesses industrial psychology’s influence on three important nursing inquiries, stimulated by the shortage of nurses and preparations for a national health service: the Lancet Commission (1932), the Interdepartmental Committee on Nursing Services (Athlone Report, 1937) and the Working Party on Nurse Recruitment and Training (Wood Report, 1946). It explores why nurses’ mental health gained importance at a national level and whether the reports’ ideas and recommendations impacted on the ways nurses were managed in the case study institutions. Finally, the concluding chapter assesses the ways the construction of nurses’ health reflected wider debates about disease in society rather than identifying exactly what it was about the work that produced a risk of ill-­health. Notes  1 Pall Mall Gazette (11, 17 September 1890).  2 Ibid. (7 September 1890).  3 Health and Safety Executive, A Pilot Study into Improving Sickness Absence Recording in National Health Service Acute Trusts (2007). www.hse.gov.uk/ research/rrpdf/rr531.pdf. Accessed 1 May 2012.  4 S. Boorman, NHS Health and Well-­ being Final Report November 2009 (Department of Health, 2009). www.nhshealthandwellbeing.org/FinalReport. html. Accessed 1 May 2012.  5 ‘Tackling staff sickness and absenteeism’, Nursing Times (30 April 2012).

8

Introduction  6 Boorman, NHS Health and Well-­being, p. 10.  7 Ibid.  8 Healthcare Commission, Ward Staffing (June 2005), 17. http://archive.cqc. org.uk/_db/_documents/04018124.pdf. Accessed 31 May 2012.  9 Department of Education, School Work Force in England (November 2011). www.education.gov.uk/rsgateway/DB/SFR/s001062/index.shtml. Accessed 31 May 2012. 10 N. Morris, ‘“Shocking” sickness rates in social work’, Independent (16 September 2009); Unison, Sickness Absence, 2010. www.unison.org.uk/ safety/sickdocs.asp. Accessed 14 September 2012. 11 Sickness Absence Rates in the NHS, October – December 2011, p. 11. www. ic.nhs.uk/webfiles/publications/010_Workforce/Sickness_Absence_OCT-­D EC11/NHS_Sickness_Absence_Oct_Dec2011_Report.pdf. Accessed 31 May 2012. 12 D. Brown, ‘Nurses and preventable back injuries’, American Journal of Critical Care, 12:5 (2003), 400–1; A. Davenport, ‘How to protect yourself after body fluid exposure’, Nursing, 39:5 (May 2009), 22–8; J. Jemmott and J. Freleicher, ‘Perceived risk of infection and attitudes towards risk groups: determinants of nurses’ behavioural intentions regarding AIDS patients’, Research in Nursing and Health, 15:4 (August 1992), 295–301; D. Kindy, S. Petersen and D. Parkhurst, ‘Perilous work: nurses’ experiences in psychiatric units with high risks of assault’, Archives of Psychiatric Nursing, 19:4 (August 2005), 169–75. 13 T. Joyce, M. Hazelton and M. McMillan, ‘Nurses with mental illness: their workplace experience’, International Journal of Mental Health Nursing, 16:6 (December 2007), 373–80; K. Hawton and L. Vislisel, ‘Suicide in nurses’, Suicide and Life-­Threatening Behavior, 29 (1999), 86–95; G. Clews, ‘NHS stress driving up nurse sick leave levels’, Nursing Times (14 April 2009). 14 Boorman, NHS Health and Well-­being, pp. 8–9. 15 M. Carpenter, Working for Health: The History of COHSE (London: Lawrence & Wishart, 1988), p. 27. 16 B. Harrison and H. Mockett, ‘Women in the factory: the state and factory legislation in nineteenth century Britain’ in L. Jamieson and H. Corr (eds), State, Private Life and Political Change (London: Macmillan, 1990). 17 Shuttle kissing refers to the weaver’s practice of loading new cops of thread into the weaving shuttles by putting one’s lips over the outside of the shuttle eye and inhaling to draw the thread through. See C. Malone, ‘Gendered discourses and the making of protective labour legislation in England, 1830–1914’, Journal of British Studies, 37:2 (April 1998), 166–91; A. Fowler, Lancashire Cotton Operatives and Work, 1900–1950: A Social History of Lancashire Cotton Operatives in the Twentieth Century (Aldershot: Ashgate, 2003); J. Greenlees, ‘“Stop kissing and steaming!”: tuberculosis and the occupational health movements in Massachusetts and Lancashire, 1870–1918’, Urban History, 32:2 (2005), 223–46.

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Who cared for the carers? 18 B. Harrison, Not Only the ‘Dangerous Trades’: Women’s Work and Health in Britain, 1880–1914 (Abingdon: Taylor & Francis, 1996), p. 106. 19 P. D’Antonio, ‘Revisiting and rethinking the rewriting of nursing history’, Bulletin of the History of Medicine, 73:2 (1999), 271. 20 B. Abel-­Smith, A History of the Nursing Profession (London: Heinemann, 1960), p. 132; C. Hart, Behind the Mask: Nurses, Their Unions and Nursing Policy (London: Ballière Tindall, 1994), p. 41.

10

1

‘To help a million sick, you must kill a few nurses’:1 the impact of the campaign for professional status on nurses’ health, 1890–19142 ‘To help a million sick’

In 1890, probationer nurse Ellen Yatman told the Select Committee of the House of Lords on the Metropolitan Hospitals that nursing caused her ill-­health.3 During her eighteen months of training at The London Hospital, Yatman complained that she, like ‘most of the nurses’, constantly suffered from ‘overwork’ and ‘overtiredness’. The causes of her fatigue, she believed, included an eighty-­three-­hour working week and the onerous, menial cleaning duties that took up most of her working day. She also protested that a shortage of trained staff placed inexperienced nurses in positions of overwhelming responsibility and that overcrowded wards were inadequately staffed.4 Yatman’s short-­lived nursing career came to an end when she contracted ‘blood poisoning from sewer gas’, a smell she believed emanated from the sink basins in her ward but which affected most parts of the hospital. This chapter examines the ways attitudes towards nurses’ health at the three case study hospitals were shaped by the professionalisation of nursing. Nursing was drawn into the political spotlight at the end of the nineteenth century. The campaign for nurse registration began in 1887, prompting doctors and nurses to redefine nurses’ work and place in the hospital hierarchy: commentators often supported their arguments for and against change with reference to nurses’ health. As we will see, supporters and opponents of registration had very different ideas about the organisation of nursing. These ideas not only shaped national nurse organisations’ strategies but also affected individual nurses’ experiences of illness. 11

Who cared for the carers?

Campaign for nurse registration The campaign for nurse registration began when a disagreement between Henry Burdett and various matrons, including Ethel Gordon Manson (1857–1947), led to the formation of the splinter group British Nurses’ Association (BNA) from Burdett’s Hospital Association.5 Gordon Manson was elected matron of St Bartholomew’s Hospital in 1881, at the age of twenty-­four, but resigned on her marriage in 1887 to Dr Bedford Fenwick. She acquired Nursing Record in 1893 and became its editor. In 1903 it was renamed The British Journal of Nursing (BJN). Through its pages, for the next forty-­four years, her thinking and beliefs are revealed. She was important as registration’s leading advocate, wishing to establish nursing as an autonomous profession, controlling its own fees and conditions of service. Registration’s opponents, led by Eva Luckes, wished to maintain the voluntary hospitals’ existing system of management.6 The Select Committee of the House of Lords was the first public forum in which the registration debate was aired.7 The committee was set up in 1890 following complaints by some of The London Hospital’s governors to the Charity Organisation Society.8 The governors were aggrieved that, among other things, the position of matron had become too powerful. The Charity Organisation Society petitioned Lord Sandhurst, demanding that a Select Committee of the House of Lords should inquire into the work of the metropolitan hospitals. The committee was highly politicised and set out many of registration protagonists’ objectives. Gordon Fenwick focused on the need for professional self-­regulation, advocating establishment of a controlling body to regulate education and work conditions. Luckes set out to demonstrate that individual hospitals were capable of setting high standards of behaviour without state regulation. The select committee was given a broad charge but spent a substantial amount of time examining witnesses from The London Hospital. Of the twenty-­three meetings held, ten were concerned with The London Hospital and with allegations that it neglected nurses’ health. Several contemporary newspaper reports questioned the reliability of the committee’s evidence,9 suggesting that Gordon Fenwick had planted witnesses who held a grudge against Luckes. 12

‘To help a million sick’

Newspaper coverage of the proceedings undoubtedly reflected allegiances to parties in the registration campaign. For example, the Pall Mall Gazette was against The London Hospital; The Hospital (run by Burdett) was for The London Hospital and against registration; the Nursing Record was against The London Hospital and for registration. ‘To help a million sick, you must kill a few nurses’ was typical of several headlines in the Pall Mall Gazette, designed to shock its readership and discredit The London Hospital.10 Registration’s supporters and opponents did agree on the need to attract more middle-­class recruits as a way of raising nursing’s status.11 It was, therefore, the special attributes and vulnerabilities of middle-­class women that framed discourses about the organisation of nursing and nurses’ health. Citing nurses’ health gave credibility to the necessity for improvements to working and living conditions. It was also used to limit change by suggesting that middle-­class women lacked the physical and mental strength of their working-­class counterparts and were unable to perform the menial tasks implicit to nineteenth-­century nursing. The London Hospital The London Hospital was a large metropolitan voluntary teaching hospital whose nursing staff consisted of matron Eva Luckes and her four assistants, nineteen ward sisters and 212 nurses and probationers caring for an average of 626 patients.12 Eight nurses died between 1888 and 1890, compared to seven nurses who died in the previous eight years.13 It is difficult to confirm whether rising mortality and morbidity rates among nurses were a general trend without comparative data from other hospitals, a point argued by the British Medical Journal (BMJ) at the time. The BMJ also questioned whether the increasing number of deaths simply reflected the fact the number of nurses employed had risen. Commentators alleged that Luckes misused her considerable power to force nurses to work even when ill, and, consequently, morbidity and mortality rates had risen.14 Nurses alleged that they were too scared to report sick for fear that they would be dismissed.15 These allegations attracted significant press interest because of their relationship to the campaign for nurse registration. The rising 13

Who cared for the carers?

mortality rate suggested that The London Hospital had a serious health problem, and commentators were keen to explain why. Attention focused on Luckes’s system of discipline and its effect on the health of nurses. Luckes accrued considerable power during her first ten years as matron, causing resentment among some of the hospital’s thirty lay governors.16 Luckes was from an upper-­class background and had the advantage of a Cheltenham College education. She trained at the Westminster Hospital and, after several months as a night sister at The London Hospital, she became lady superintendent at the Pendlebury Children’s Hospital, Manchester. She resigned from this post after clashing with the medical committee over her efforts to instigate reforms in nurse training. She was appointed matron at The London Hospital in 1880 at the age of twenty-­four. Some of the lay governing committee thought her too young and inexperienced at her interview but a small majority selected her on the grounds that she had already constructed a step-­ by-­ step programme of reform.17 Luckes achieved her position of authority by improving nurse education and writing textbooks. Although she argued that the ability to nurse was a ‘natural’ inherent quality, that ‘you can no more make a nurse of a woman who has not a gift for nursing than you can make a musician of a person who has no ear for music’, she promoted a scientific approach to nurse education and practice.18 In 1881, she introduced a system of theoretical and practical training, and, in 1884, she published her Lectures on General Nursing, adding Lectures to Ward Sisters in a second edition two years later.19 By 1890, she had established herself as an expert on nursing practice, thus legitimising her challenge to an entrenched governors’ committee who assumed her youth meant lack of experience and sought to limit her drive for reform. Doctors played little part in the management of the hospital and were not allowed to sit on either the governing or the house committee. The lay committee, who came from a variety of backgrounds including the City, the military and the landed gentry, were entirely responsible for all aspects of policy. Doctors generally supported the ways Luckes exercised power over the nursing department. In order to demonstrate The London Hospital’s ability to set high 14

‘To help a million sick’

standards of professional behaviour without state regulation, Luckes enforced a militarised system of discipline that incorporated the care of sick nurses. Expectations that nurses would endure ill-­health were intended to show that disciplined training produced a superior type of nurse who did not need state registration to prove her quality. Luckes used the analogy of a soldier’s commitment to personal sacrifice to illustrate the devotion to duty she required of nurses facing the risk of contracting infection. Women who fear infection for themselves are greatly to be pitied, but they have no business to be nurses … it is this element of personal danger … which places the work of soldiers and of nurses on the same level. Nothing can tempt the true nurse or the true soldier from the post of danger when duty places them there. It is this very fact that sheds a halo over the ideal of a nurse’s work.20

Luckes acknowledged that a nurse’s death may arise as a ‘direct consequence of attending to her patient’ but claimed this was a price worth paying to ‘sanctify the work’ and inspire others. Self-­sacrifice was perceived to be an essential quality in the professional nurse, demonstrated by her disregarding her own ill-­health. Nurses who failed to achieve this difficult goal were often perceived as self-­centred troublemakers who lacked the vocation to nurse. Yatman, whose case was mentioned earlier, represented most aspects of the image of the ‘new’ nurse. Educated and middle-­class, she had many of the qualities that nurse leaders promoted as vital to distinguish the new nurse from her supposedly ignorant, immoral, working-­class predecessor. Historiography has challenged the myth of ‘old’ and ‘new’ nurses. Traditional interpretations accepted these images at face value,21 but Anne Summers argues that doctors used the Sarah Gamp figure to discredit old domiciliary nurses because they threatened their monopoly.22 Sue Hawkins contends that nurse leaders also feared domiciliary nurses’ independence because it made them difficult to control.23 What Yatman lacked, according to Luckes, was the essential quality of self-­sacrifice: she was not prepared to endure ill-­health as part of her commitment to duty. Despite Yatman’s admission to the nurses’ sick room with an illness affecting several other nurses, Luckes doubted its authenticity, noting in the probationers’ register that: 15

Who cared for the carers? Ellen Yatman was constantly complained of as an idle, unpleasant and inefficient nurse; she was very selfish in worth, thinking last of her patients and much of her own convenience. She was an inveterate grumbler and by no means straightforward. She had no scruple in breaking her engagement when she fancied her health broken down.24

Luckes implies that Yatman imagined her ill-­health, a character failing she often linked with a selfish personality. Indeed, Luckes’s suspicious attitude toward nurses’ health shaped nurses’ response to sickness. Several confessed a reluctance to admit ill-­health for fear of being labelled unsuitable and dismissed. Luckes denied such a practice existed, reassuring the select committee that she never sent nurses away on health grounds, unless instructed by a doctor, and that she always allowed ample time for nurses to recover.25 However, nurse Mary Raymond testified that nurses ‘did not like to apply’ to see a doctor ‘and to say that they are ill. They are liable to get dismissed.’26 Probationer Vannah Edwards, who died from pneumonia after eighteen months of training, was apparently too frightened to admit she was ill. Raymond described to the select committee how hard Edwards worked: until she was quite unfit; she was so ill that she could hardly breathe and excused herself from supper; the home sister went to her room, found that she had a high fever; and sent for the house physician, who ordered her at once to be warded; 10 days after that she was dead.27

Although Luckes encouraged nurses to share their problems with her ‘at home’ in her office every Tuesday evening, nurses did not complain.28 According to nurse Violet Dickinson, ‘we all felt that it would be bad for ourselves if we were to make a complaint’.29 Dependent on a future reference, sick or dissatisfied probationers recognised that Luckes interpreted poor health or criticism as a lack of vocation to nurse. Luckes also implemented significant improvements to working conditions. One reason she was appointed was because she had already constructed a programme of reform. Despite numerous disagreements with the governors and house committee about expenditures, she introduced several significant reforms. For example, in 1881, nurses’ diets were improved and their workload reduced with the employment of twenty-­two ward maids.30 By 1890, Luckes 16

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had convinced the chairman of the house committee, Francis Carr Gomm, that she should be ‘entirely responsible for nursing management’.31 This decision led to the allegation ‘that too much power is entrusted to the matron’, which was debated at length by the Select Committee of the House of Lords on Metropolitan Hospitals.32 The apparent high levels of nurses’ illness and their rising mortality were used to question and undermine her ability to hold a position of authority. Luckes clearly cared about nurses’ health, as evinced by the effort she made to improve their working conditions. However, she considered dedication to duty, obedience and self-­sacrifice more important. She extended a system of health care to nurses, partly with the aim of increasing her authority over their lives. In 1885, Luckes introduced a compulsory medical examination at the end of a month’s trial period and used it to weed out probationers who did not fit her expectations. Despite a satisfactory ward report and ‘a slight sore throat for one day’, Luckes dismissed probationer Howard-­Jones at the end of her trial period on health grounds. Howard-­Jones claimed her health to be excellent, which she then illustrated by immediately applying to another hospital in London, passing its physical examination, successfully completing training and eventually becoming a hospital matron.33 Success in passing the medical examination also depended on whether Dr Samuel Fenwick (Dr Bedford Fenwick’s father) judged a probationer of sufficient physical strength to work long hours and live in the densely populated East End of London ‘away from any means of recreation’. Samuel Fenwick was senior honorary physician and a strong ally of Luckes. He argued that probationers needed to be of a particularly strong physical constitution to work at The London Hospital because of the poor quality of the surrounding air.34 In 1886, Luckes changed nurses’ rules to specify that sick probationers could no longer choose any doctor from the resident staff but had to consult honorary staff physicians Dr Samuel Fenwick, Dr Henry Gawen Sutton or surgeon Mr Frederick Treves. Previously, nurses had consulted junior house surgeons or physicians but Luckes argued that ‘many nurses very naturally object to consulting the young doctors about their own health’.35 Senior doctors were also believed to more adept at uncovering nurses who, according to the 17

Who cared for the carers?

hospital chaplain, ‘were generally prone to malingering’.36 Samuel Fenwick admitted that he did not take the majority of cases seriously as most complaints were ‘trivial … a little sore throat, a headache; it may be any little trivial thing’.37 To add to their problems, nurses were not given any privacy during their consultations, which took place in the presence of a ward sister, house physician and consultant. The fact that nurses were denied a choice of medical staff or privacy must have been difficult for those with more experience such as Janet Page. Page entered training at The London Hospital in June 1888, aged twenty-­seven, with three years’ previous nursing experience at Highgate Infirmary. Her application for a staff nurse post was declined because of The London Hospital’s rule that nurses from provincial or smaller metropolitan hospitals must enter as probationers and complete the two-­year training programme. She was dismissed after eleven months for consulting a doctor other than one of those designated by Luckes regarding chronic leg ulcers.38 Page’s ulcers badly affected her; the pain was such that her sleep was disturbed. She worried that, if she consulted the appointed doctor, he would not adhere to the confidential practice expected in the doctor–patient relationship. She therefore consulted Bedford Fenwick, then a junior house physician. Bedford Fenwick had held all the house appointments at The London Hospital but unlike his father, Samuel Fenwick, had been unsuccessful in getting elected to the staff. As mentioned earlier he married Ethel Gordon Manson in 1887.39 Anxious that she would be dismissed on health grounds if she disclosed her history of chronic leg ulcers, Page complained only of sleeplessness, for which she was prescribed a draught. After two weeks with no improvement, Page consulted an ‘outside’ physician, Dr Anderson, who admitted her as an in-­patient to The London Hospital. On finding Page admitted to a ward, Luckes promptly dismissed her on the grounds of inefficiency. Page’s failure to ask Luckes’s permission to consult an outside doctor or apologise for doing so was interpreted as a laxity in discipline by Luckes and Samuel Fenwick, who advised Luckes on such matters.40 Page had a history of unreliability, was frequently reported ‘as incapable of getting on with her work’ and had failed to disclose serious health problems at her initial medical examination.41 Luckes was keen to dismiss her. Page, Luckes recorded, ‘was not at all strong and proved 18

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mentally and physically unsuitable for the work she had entered upon’.42 The Select Committee of the House of Lords on Metropolitan Hospitals heard from Luckes how Page had proved unsuitable for further training … She gave me a good deal of trouble during the few months she was with us, partly, though I fear, not entirely caused by her very bad health. She may have tried to improve, but she never appeared to do so.43

Luckes’s report suggests that Page suffered from both poor health and a lack of self-­discipline. This case illustrates some of the difficulties facing a historical analysis of the relationship between health and discipline. Long-­term health problems obviously had an impact on nurses’ work and may have influenced qualities such as reliability, enthusiasm and determination. However, it is a mistake to assume that health was the only factor shaping a nurse’s behaviour and aptitude for discipline. The fact that Luckes did not discuss other influences in the probationers’ registers reinforces the impression that for her it was the main cause of ill-­discipline. Her description of Ellen Stocking, ‘a self-­absorbed person of little practical use’ who ‘had not good health’,44 or of Maud Parsons, who was ‘essentially feeble in every way and was very slow and stupid … continually going to the sick room with boils on her neck’45 are typical of those with health problems and stand in contrast to that of healthy nurses like nurse Walmsley, who ‘worked conscientiously and well without being at all brilliant … her health was particularly good so there was an opportune vacancy’. The high value Luckes placed on physical health as a requirement to nurse may have been justified by the fact that nursing in this period was ‘extremely heavy’, demanding physical strength and endurance.46 A lack of clarity about the transference of disease also problematised health issues. In the late nineteenth century, nurses’ health risk was understood in terms of two categories of illness: infection and overwork. Seven of the eight deaths among nurses between 1888 and 1890 were attributed to infectious diseases; two died from scarlet fever, one from diphtheria, two from pneumonia, one from blood poisoning after contracting a septic finger47 and one from suppurative meningitis.48 However, ideas about the risk of infection were obfuscated by understandings of the germ theory of disease. Michael 19

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Worboys argues that, although there was a growing consensus in medicine after 1880 that most disease germs were bacteria, there was no agreement on a single bacterial model or its actions.49 At The London Hospital, doctors, nurses and the former hospital chaplain offered various opinions about the cause of infectious diseases among nurses. Luckes considered the infectious patient the main risk factor and instructed nurses about infection control. For example, nurses caring for patients with diphtheria were taught the importance of frequent hand washing with a Lysol solution particularly before eating, not eating food in patients’ rooms and gargling twice a day but remembering to remove their false teeth before doing so.50 An outbreak of diphtheria and scarlet fever among six nurses from the same ward in October 1888 prompted debate about the possible causes of infection. The problem was accentuated when one of the nurses, Katherine Woolley, died. Paying probationer Woolley became ill with scarlet fever only two weeks after starting training, suggesting that probationers in their initial period of employment were more susceptible to infection.51 The BMJ considered that nurses who were not ‘protected by a previous attack’ were more likely ‘to be affected when brought into contact with it’.52 Gordon Fenwick supported a reduction in first-­year probationers’ working hours and an increase in holiday leave, on the grounds of increased vulnerability to illness during the initial six months of training.53 Several nurses believed that the smell from poor sanitation was responsible for their high levels of infection, particularly the sore throats that were common in the first year of training.54 Miasmic theories continued to influence thinking about contributing factors to disease, although from the 1860s the term was increasingly applied to catching airborne diseases, either directly from other people or from the environment.55 A former chaplain of The London Hospital, Henry Valentine, who resigned from his post following strange allegations that he pressurised nurses to take confession, told the Select Committee of the House of Lords on Metropolitan Hospitals that the match-­boarding or lath and plaster partitions of the sisters’ rooms, adjacent to their wards, were too thin and allowed ‘the smell and often the stench of gangrene or cancer’ to ooze ‘through the cracks and crevices of their rooms’. Although infected patients were likely to have surgery in the late 20

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nineteenth century to debride the wound, they remained in-­patients for long periods of time. Valentine described the case of a man ‘who lay there for days and days, to the great hurt of all the patients … for many days the whole ward was unfit really to live in’. Because ward sisters’ rules dictated that they always slept in their rooms, Valentine recommended that they ‘be allowed to sleep in pure air at least once a month’.56 In 1889, The London Hospital medical staff admitted their perplexity as to the cause of the various symptoms nurses suffered, suggesting that they pointed to ‘unsanitary conditions of some kind’.57 An investigation by the house governor William Nixon concluded that the cause of the smell was not sewer gas but coal gas ‘which is very unpleasant in smell but not as unwholesome as sewer gas’.58 (With hindsight, and in our knowledge of the toxicity of coal gas, his statement seems naive.) However, in 1890, the doctors’ concern for nurses’ health persuaded the house committee to invest £7,000 for improving sanitation.59 Despite the evident risk that infectious diseases posed to nurses’ health, conversations obscured the issue by suggesting that women’s limited physical strength and an increase in the number of middle-­class recruits were responsible for the rise in morbidity and mortality. Such claims had the potential to undermine nurse leaders’ campaign for professional status: middle-­class recruits were perceived as vital to transforming nursing into a ‘respectable’ profession, but their identification as a group vulnerable to health problems could have deterred possible candidates. Historiography regarding gender and nursing highlights nurse leaders’ use of gender ideologies and imagery to promote their case for professional status.60 Luckes argued that ‘a sister of a ward must not only be a good Nurse, but she needs also all the qualifications of the general head of a household’.61 Women’s right to nurse derived not only from the management skills learned from organising domestic households but also from their biological capacity for motherhood. Despite Luckes’s introduction of a more scientifically based system of nurse training tested by examination, she maintained that ‘women who would make the best mothers make the best nurses’. For this reason, she argued that nurses’ work conditions should remain unregulated like mothers: ‘the duties of a true mother and of a real nurse are not merely mechanical and their 21

Who cared for the carers?

work cannot advantageously be regulated as though that were the case’.62 Complementing her opposition to state registration and her belief that individual hospitals should be responsible for setting work conditions, Luckes argued against a national system of regulation because it would be detrimental to nurses’ welfare. Such arguments were problematic; they were a source of strength but created a ­boundary around health issues. It became difficult for nurse leaders to identify health hazards or demand a reduction in working hours when the model of motherhood as a framework for nursing implied a twenty-­four-­hour commitment and a duty of self-­sacrifice. The relationship between nurses’ gender and health attracted the attention of the medical press and the Select Committee of the House of Lords on Metropolitan Hospitals. Some doctors, fearing that nursing reform might lead to a backdoor route into medicine, argued that women were not physically equipped to deal with nursing’s poor work conditions.63 A study in the Lancet, in 1890, suggested that women were not strong enough to work twelve-­hour nursing shifts, which were described as ‘a cruel strain on a woman’s strength and nerve’.64 Samuel Fenwick agreed that woman’s natural fragility combined with long working hours caused a high incidence of varicose veins and ‘flat foot’.65 Flat feet were a common problem among nurses and often cited as the reason for nurses’ dismissal. Frederick Treves, a surgeon at The London Hospital, who opposed state registration because it threatened the general practitioner’s income, identified nurses’ social class as the cause of flat feet. He claimed that the arch of the foot sank ‘in a woman of feeble physique’, particularly ‘ladies who have been accustomed to not much standing, nor much walking’.66 Treves suggested that nurses should continue to be drawn from working-­class backgrounds, ostensibly to prevent the increasing incidence of flat feet, but this also suited his political agenda. He, like other members of the medical profession, was concerned that middle-­class, articulate nurses might become more independent in their work, follow their own professional rules and compete with general practitioners. The theme of class, as mentioned earlier, was important in the struggle to define the boundary between ‘old’ and ‘new’ nurses and was crucial in nurse leaders’ attempts to organise nursing more formally and establish its status in the division of labour. Conversations focused 22

‘To help a million sick’

on whether nursing was to be a new profession for educated, middle-­ class women or a refined form of domestic service with a subordinate place in the hospital.67 The London Hospital increased its number of middle-­class recruits with the introduction of a three-­month training scheme for paying probationers in 1881, but its numbers were small; in 1890 only fourteen probationers paid out of 134 nurses.68 This evidence support Hawkins’s conclusions that nurses in this period were drawn from a wide range of backgrounds.69 Indeed, Luckes justified her agenda for improvements to nurses’ sleeping accommodation because the ‘mixed classes’ employed deserved comfort.70 However, she prioritised the physical and mental health needs of a core group of middle-­class nurses. She offered the idea that these nurses needed more space and privacy than working-­ class women: ‘the trial to women of the better class, of never being alone for five minutes out of the twenty-­four hours, is one that perhaps can hardly be estimated without personal experience of it’.71 These views probably reflected Luckes’s own upper-­class background mentioned earlier. Paying probationers’ complaints to the Select Committee on Metropolitan Hospitals suggest that they expected preferential treatment. Eliza Homersham had expected a separate bedroom but was put in a dormitory with eight women including working-­class ‘sewing women’ who slept in her bed whilst she was on night duty. ‘No lady’, Homersham complained, ‘likes to think her bed is occupied alternately by a stranger whose habits are different to her own.’ It was not a lack of personal space that troubled Homersham but more the fact that she was expected to share a bed with a working-­class woman.72 The system of ‘boxing and coxing’, where day and night nurses or night nurses and servants shared a bed, continued until at least 1890. Homersham also complained about the poor standard of nurses’ accommodation and the fact that she had to fetch hot water from a copper in the basement.73 The Hospital suggested that the introduction of an educated and articulate minority was responsible for an increase in the number of complaints: a class of women superior to that known to a previous generation has brought with its many advantages certain drawbacks. Among others it has opened the door to a restless, self-­conscious and ambitious element out of place in a calling which, for its highest fulfillment, demands a large measure of person suppression and self-­sacrifice.74

23

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Middle-­class nurses were perceived as ambitious and less willing to sacrifice their personal liberty. The idea that these women might have complained to improve occupational standards was ignored. Newspapers and the medical press debated the relationship between health and class background in an attempt to define the hospital nurse’s role. According to Pall Mall Gazette and the Lancet, middle-­class nurses lacked the physical strength and stamina to perform menial work and would be better employed in management and personal care tasks: Such nurses were not material that any master hand [would] select for steady and continuous work. Domestic tasks that come lightly to women of tougher fibre [were] a strain to them, but they work with hearty goodwill, and unreliable as their health may be they [were] a valuable element in a nursing staff.75

The Lancet advised that middle-­class nurses spend their time on patient care because ‘of the delicacy of their hands’ rather than on ‘rough tasks’ that ‘ought not to be imposed on ladies whose utmost strength is heavily taxed’.76 As medical knowledge changed, doctors required efficient assistants: a nurse who spent more time performing patient care would be better able to observe the patient’s condition and report back to medical staff.77 In contrast, The Hospital argued that social background had no part to play in dictating the nurse’s role reinforcing an ideology of nurses as self-­sacrificing angels who tolerated all working environments to fulfil their devotion to duty.78 In reply to suggestions that middle-­class women lacked the physical strength to nurse, Luckes promoted an image of The London Hospital nurse as physically and mentally superior to ‘ordinary women’. This strength, she argued enabled them to cope with the health risks of nursing: ‘I think nurses are not ordinary women, or they never would come and choose work that causes so much tax to their energies, physically and mentally and feelings altogether.’ Such an image implied invulnerability to illness, and, indeed, Luckes rejected demands for a reduction in working hours because, in her opinion, superior physical strength guaranteed good health ‘barring accidents incidental to the work’.79 The idea that the nurse was a superior type of woman reflected, in some ways, a wider debate surrounding the image of ‘new women’ during the 1890s. A literary stereotype, constructed as a result of 24

‘To help a million sick’

debates over marriage, sexualities, political rights, labour rights, lifestyles and fashion, the new woman signified the single woman’s bid for personal freedom in the form of a career, financial independence, suffrage and leisure.80 A feminist ideal, the image challenged traditional gender roles of domesticity and motherhood and pushed against the limits of a male-­dominated society. Luckes did not see a problem in promoting almost contradictory images of The London Hospital nurse, as both a ‘superior’ type of career woman and a mother. Nurses were trying to develop an image of the profession built on traditional gender roles while competing for more powerful positions in male-­dominated hospitals. The way Luckes treated nurses’ health was distinctive; its foundations stemmed from her significant power to shape nurse policy. Because she was a major national figure, it might be expected that such a model would be replicated elsewhere. However, this was not necessarily the case. Even in her own institution, some rank and file nurses and their parents registered opposition to the denial of their health concerns. For example, Ellen Yatman’s father wrote to Luckes ‘pointing out the unnecessary hardships and dangers to which nurses were exposed. The matron returned a bare acknowledgement of the letter.’81 Other institutions facing similar issues to The London Hospital approached the problem completely differently. Systems of discipline and patterns of occupational health care varied between institutions, partly, because of the matron’s political views about the professionalisation of nursing. The SDEC Hospital in Plymouth and the Cornwall Lunatic Asylum in Bodmin demonstrate this point. The South Devon and East Cornwall Hospital The SDEC was a provincial voluntary hospital in Plymouth, Devon, chosen for this study because its matron held a different political viewpoint from Luckes regarding registration. Its geographical position, 223 miles from London, and its smaller size also make it an excellent comparator. The SDEC opened in 1840 and by 1890 employed eleven nurses and eight probationers to care for 124 patients. All probationers paid £26 annually for their two-­year training.82 The cost of a nurse’s board and lodging was estimated to be £18 per annum. The SDEC lacked the resources of The London Hospital, making 25

Who cared for the carers?

it unlikely that policies could be replicated but its range of services expanded rapidly at the end of the nineteenth century when a clinical laboratory was built and, in 1901, an X-­ray department opened, one of the first in Britain.83 Matron Harriet Hopkins treated health and disciplinary issues as entirely separate. Whereas evidence from The London Hospital supports Anne Witz and Brian Abel-­Smith’s views that voluntary hospital matrons had established themselves as heads of independent nursing departments by the end of the nineteenth century, the SDEC supports Stuart Wildman’s thesis that there were significant variations in the matron’s influence.84 Hopkins trained at Charing Cross Hospital, a prestigious London teaching hospital, and was appointed SDEC matron in 1886 from a large field of applicants. She was a member of the general council of the BNA,85 and also sat on the executive committee of the Matrons’ Council, organisations that supported nurse registration. Although there is no record of Hopkins’s personal views on registration, the fact that she regularly used her annual leave to travel the long ­distance from Plymouth to London to attend meetings, suggests significant commitment to nurse education, training and developing the matron’s role.86 These issues dominated the agendas of both organisations during the years of Hopkins’s membership. However, one must be wary of assuming that her membership confirms her support of registration. Rafferty argues that BNA members may have been recruited for reasons of ‘patronage, power, status and respectability’, not necessarily for their political commitment to registration.87 The BNA agenda was concerned with nurses’ pay and health as well as registration.88 Nurses’ health was a contentious issue provoking bitter disagreement between Luckes and the BNA. Luckes disapproved of the BNA’s proposals to ‘establish a sick fund, an annuity fund, and a house of rest’ for sick nurses.89 Convalescence homes were unnecessary, Luckes argued, because so few nurses were sick.90 She considered it the individual hospital’s responsibility to encourage the public to take sick nurses into their homes. Political tensions also developed between Gordon Fenwick and her allies, and the medical members of the BNA, particularly after it received its royal charter in 1893. Gordon Fenwick’s control of the BNA diminished as it diverted from its pre-­registration agenda, and she turned to the Matrons’ Council as an alternative forum to discuss professional issues.91 26

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The Matrons’ Council of Great Britain and Ireland, founded in 1894 by Isla Stewart, who succeeded Gordon Fenwick as matron of St Bartholomew’s Hospital, became the only organisation devoted to the cause of registration following the 1896 BNA’s resolution opposing registration. Hopkins attended the Matrons’ Council’s inaugural meeting on 13 July 1894 and played a part in shaping its by-­laws by seconding a proposal that it include a range of professional and general topics at future meetings. Other by-­laws included promoting a uniform system of education and training and providing matrons the opportunity to receive professional support.92 Hopkins was one of twenty-­one elected executive committee members from 1894 to 1898, when she resigned from the position of vice chairman because of her ‘inability to attend the meetings’.93 As a newly appointed matron in 1896, Hopkins introduced several changes to the SDEC that reflected BNA policy. For example, the BNA considered a three-­year training programme necessary as qualification for registration. Hopkins extended nurse training by six months, from three to three and a half years, to include eighteen months of theoretical training alongside ward experience and eighteen months as a member of the hospital staff.94 The BNA also discussed the advantages of specialist training: for example, Catherine Wood, BNA honorary secretary and lady superintendent of the Hospital for Sick Children, Great Ormond Street, stressed the importance of training nurses for sick children.95 Hopkins subsequently appointed a trained children’s nurse at the SDEC.96 In July 1890, the issue of nurses’ health began to attract the SDEC governing committee’s attention, although what prompted this interest is unknown. Probationers were now asked to provide a certificate of health from a qualified doctor on commencing training and were also subject to a health examination at the end of their three-­month probationary period. There is no evidence that Hopkins used this as an opportunity to weed out unsuitable applicants. Hopkins was also asked to present a weekly report about the ‘health of the nursing staff’.97 This new concern did not prompt any changes to Hopkins’s system of nurse discipline. Health matters continued to be treated on their own merit and not as an indication of a vocation to duty. Consequently, nurse health care was more flexible than the type offered to nurses at The London Hospital. 27

Who cared for the carers?

Sick probationers and trained nurses were allowed to consult any doctor from the senior honorary staff or even outside doctors.98 Nurses with short-­and long-­term illnesses were not dismissed but encouraged to recuperate at home and return to work. In 1898, a ward side room was set up as a nurses’ sick room.99 In contrast to The London Hospital, which sent recovering nurses to convalesce in private homes, the SDEC had its own convalescence home, a large house donated by Edwin Alonzo Pearn. There is no evidence that nurses’ illness provoked suspicion. In 1905, twenty-­seven-­year-­old probationer Georgina Birch’s diagnosis of rheumatism forced her to interrupt her training for more than three years. She returned in August 1909 and gained her hospital certificate in March 1911, eight years after starting training. Hopkins recorded that Birch was ‘truthful, obedient, most polite, punctual, with good memory, unselfish, conscientious, and painstaking’. These positive comments, highlighting good moral character, suggest Birch’s poor health was not interpreted as indicative of a lack of vocation to nurse. Hopkins, like Luckes, judged moral character as a test of suitability but, unlike Luckes, did not perceive ill-­health as an indicator of its absence. Hopkins also adopted a tolerant attitude to nurses with shorter and more frequent episodes of illness. Cecily Blacker, aged twenty-­five, had neuralgia for five days in February 1909. Two weeks later, she contracted bronchitis and was sick for four months, followed by a two-­ week episode of laryngitis six months after. Hopkins described her as ‘an excellent nurse of very high principle but health not good’, thus distinguishing her health problems from other aspects of her character.100 As at The London Hospital, SDEC nurses faced a high risk of contracting an infectious disease. Tonsillitis was the most common illness, followed by influenza and septic finger. Probationers took an average of nineteen days to recover from tonsillitis and sixty-­eight days from septic finger.101 Probationer Alice Dowling, aged eighteen, contracted a septic finger after six months of training and again, a year later. On her being sent home to recover, her parents decided that she was not strong enough to nurse and prevented her return.102 As at The London Hospital, SDEC medical staff considered miasmic theories responsible for the high levels of infection, particularly the ‘dreadful stench from the sewer ventilator’.103 28

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Hopkins successfully managed the nursing department for eighteen years, from 1886 until 1904, without criticism from the medical staff. However, in 1904, doctors identified her as incompetent and sought to undermine her authority. Two factors unsettled the medical staff. Firstly, the Western Daily Mercury, a local newspaper, ran a series of articles in February 1904 criticising standards of nursing care at the SDEC.104 Although it is clear that these articles were partly driven by local doctors’ resentment at losing fee-­paying patients to the hospital, the derogatory publicity upset the governing committee. Local doctors claimed that patients were walking past the doors of their surgeries to the hospital, often dressed in servants’ clothes, in the hope of receiving free treatment.105 The second factor was the question of the state registration of nurses. In May 1904, the medical committee received copies of the two 1904 private members’ bills for the registration of nurses from the British Medical Association (BMA). Ethel Gordon Fenwick and Isla Stewart drew up the first bill, with the assistance of Fenwick’s husband (they had formed the Society for the State Registration of Nurses in 1902, amalgamating with the Matrons’ Council). The second was put forward by the Royal British Nurses’ Association (RBNA).106 In June 1904, a Select Committee on the Registration of Nurses was set up to inquire into the subject. The SDEC medical committee voted approval of nurse registration, perhaps following the BMA’s lead that an improvement in nurses’ technical knowledge would benefit the medical profession. National interest in registration and nurse education and their impact on doctors prompted an immediate reassessment of nurse training at the SDEC. The SDEC medical board had increased its power over management policy during Hopkins’s tenure as matron. Initially a lay committee with two medical representatives governed the hospital, but, in 1890, the Lancet applauded the committee’s decision to admit all five members of the senior honorary medical staff. In 1904, the medical staff held Hopkins responsible for press allegations about the deteriorating standards of patient care, and argued that her failure to organise a formal programme of lectures between November 1901 and March 1905 was the main cause of the problem, concluding that the nurses ‘were a general shambles’.107 Hopkins was called to account but appealed that a reorganisation of the hospital had 29

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resulted in a dramatic increase in her administrative duties. The medical board, led by Doctors Fox and Bertram Soltan, implemented their own ‘more efficient and practical training of the staff’: lectures were science-­based and included elementary bacteriology, asepsis and antisepsis but not nursing ideology.108 A nursing committee was set up ‘to have oversight of the whole of the nursing department’ and included a physician, surgeon, hospital secretary and a member nominated by the general committee but no nurse members, with Hopkins invited only to give a monthly report.109 Throughout her period of office, and in common with other matrons of the time, Hopkins did not sit on either the general or the house committee. It is ironic that it was receipt of information about the state registration of nurses, a move many nurses considered would lead to professional self-­regulation and autonomy, that prompted SDEC doctors to remove some of Hopkins’s power. For example, she had traditionally made independent decisions about the engagement and dismissal of nurses, but, in 1905, restrictions were introduced making nursing committee approval mandatory.110 There appears to be a clear difference between the culture of the SDEC and The London Hospital, in part due to matrons’ political views about the professionalisation of nursing. Other factors include the different nature of small provincial and city-­based teaching hospitals. Further analysis of other hospitals in both geographical locations is necessary before one can draw firm conclusions. A comparison of attitudes toward nurses’ health at our two voluntary hospital studies, led by politically active matrons, with that of a rural, mental asylum whose matrons were not interested in registration, will draw out the different relationship between asylum and voluntary hospital nursing politics and nurses’ occupational health. Cornwall Lunatic Asylum The Cornwall Lunatic Asylum for the reception of private patients and pauper lunatics, known locally as St Lawrence’s Hospital, opened in 1820 in Bodmin. Bodmin was the county town of Cornwall, a geographically isolated rural district, 240 miles from London. Cornwall’s economy was based on agriculture and mining with little secondary industry or commerce. Mounting overseas competition had a 30

‘To help a million sick’

catastrophic effect on the Cornish mining industry and, by 1885, 293 of the 377 tin and copper mines were idle or abandoned.111 Between 1870 and 1880, poverty and lack of employment prompted one-­ third of the whole population to leave Cornwall permanently, many emigrating to the United States, Australia, South Africa, Mexico and Canada.112 The CLA was a valuable source of employment in this period of economic hardship and in 1896 it employed seventy female and seventy-­six male nurses to care for 760 patients.113 It had both a different legislative framework from that of The London Hospital and the SDEC, and a distinct culture that meant the relationship between nurses’ health and discipline was inevitably dissimilar. It was governed by Dr Richard Adams, medical superintendent and a member of the Medico-­Psychological Association (MPA), and a lay visiting committee drawn from landowners, clergy, magistrates and Members of Parliament. Adams and the committee set and enforced the regulations governing nursing staff, subject to regular inspection by the Lunacy Commission. Established in 1845, the Lunacy Commission provided a framework for the provision and administration of institutions designed to confine the lunatic. The power of the commission was strengthened by further legislation between 1845 and 1862. The Lunacy Act of 1890 increased the power of the Lord Chancellor’s Office to monitor all places where the insane were housed and dictated their care and treatment. Joseph Melling and Bill Forsythe point out that commissioners’ roles were limited, largely confined to inspections and public criticism of poor standards.114 The Lunacy Commission was renamed the Board of Control in 1913. Some MPA members were interested in nurse training as a way of raising psychiatry’s status and, in 1895, they persuaded the General Medical Council to introduce a certificate in psychological medicine.115 Candidates had to have been resident in a hospital for three months and have attended a course of lectures. However, Adams was not interested in introducing nurse training to the CLA; indeed, it was not until 1918 that nurses there received any formal education. In 1871, Henry Maudsley, the pioneering Victorian psychiatrist, asked the MPA to set up a register of ‘good attendants’ in order to improve their status and encourage high-­quality candidates to come forward.116 No scheme was established and when, in 1895, Sir Dyce 31

Who cared for the carers?

Duckworth (treasurer of the Royal College of Physicians) proposed to the RBNA that those who passed the MPA examination should be considered for registration with the RBNA, Gordon Fenwick ­campaigned aggressively against it.117 Gordon Fenwick’s registration campaign excluded asylum nurses on the basis of their social background. She used her position as editor of Nursing Record and Hospital World to further the prejudice held by some general nurses against asylum nurses, particularly male nurses, perpetuating the view that working-­class background was naturally equated with dishonourable behaviour.118 One commentator to Nursing Record and Hospital World distinguished between the middle-­class background of general nurses and their aspirations toward training and the ‘uneducated’ male attendants ‘drawn from a class from which the majority of our leading nurse training schools have long ceased to admit nurse probationers’.119 It is interesting to note that only the male asylum nurses’ backgrounds and not their female counterparts’ were linked to unsuitability for training, suggesting that nurse leaders closely entwined notions of class and gender to discredit male nurses. Unfortunately there is no record of CLA nursing staff’s background, but there is evidence of their identification with working-­class culture, particularly trade unionism.120 Robert Dingwall, Anne Marie Rafferty and Charles Webster argue that attendants were working-­class, employed not only because of their physical strength but also because of their low-­level agricultural and workshop production skills.121 Late nineteenth-­century attempts to professionalise asylum nurses were unsuccessful. The Asylum Workers’ Association (AWA) was set up in 1895 by senior doctors in the MPA in response to the RBNA’s refusal to admit male attendants. The AWA was not a democratic organisation: dominated by medical superintendents, its attempts to convince nursing staff that they shared an identity of interest failed. Asylum staff rejected its idealised image of asylum life as ‘fantasies of those who were typically cossetted from the stresses and strains of daily life in the wards’. The AWA was unreasonable, according to Nolan, to demand professionalism from attendants who had no status, were underpaid, undervalued, overworked and received only a superficial training.122 There is no evidence that CLA nursing staff lobbied to be included 32

‘To help a million sick’

in the registration campaign. The two female matrons were unqualified nurses: Eliza Templar Vicary, matron of pauper patients, and Laura Elkless, matron of female patients, were appointed in the 1870s before most asylums had adopted any programmes of nurse training.123 Vicary and Elkless had little power to implement change in the nursing department. Vicary was the most senior, with responsibility for the largest number of patients, for which she received a higher wage.124 As at The London Hospital and the SDEC, the matrons did not sit on the management committee but, in contrast, they were not invited to present weekly or monthly reports. CLA nurses were treated as employees rather than members of a morally superior profession. The asylum’s system of discipline was strict, but its rules with more concerned with containing a large number of disturbed patients than with elevating nurses’ professional status. However, Adams was concerned about maintaining staff morality and, in 1890, dismissed attendant Carrie H. for writing a letter of ‘immoral character’ to attendant Richard R. who was given one month’s notice.125 Discipline did not apply to attendants’ health problems. Asylum nursing carried a significant risk of physical injury from violent patients, a risk that received little attention. Patients also ran a risk of injury from these encounters. Only when physical altercations between patients and attendants resulted in serious injury or death did the visiting committee inquire into the circumstances. For example, when patient Giles H. died during a struggle with two attendants, the committee heard evidence of how Giles, on arrival to the asylum, resented being pulled from his carriage and struck charge nurse attendant Stevens between the eyes. Stevens claimed ‘he did not use undue force’. Stevens and attendant Solomon explained that they had held the patient from ‘front and behind’ and, with the aid of two patients, had manhandled Giles into a padded room whilst he hit out. Solomon described the difficulties moving the patient and how ‘he struck us and I had to close with him’. The visiting committee decided that neither of the attendants was to blame for Giles’s death, which was caused ‘by a fall on a fireguard during the struggle’.126 It is interesting to note that two patients helped during this altercation, suggesting that the attendant–patient relationship was more complicated than simply that of custodian and prisoner and allowed some inmates to act as nurse assistants when required. 33

Who cared for the carers?

Attendants’ complaints about working conditions were not interpreted as a sign of a lack of vocation to nurse. Groups of attendants complained directly to the visiting committee throughout the 1890s about diet, hours of work, rate of wages, scale of pensions and lack of uniforms.127 Their complaints were often supported by the Lunacy Commissioners’ Reports, which repeatedly criticised the visiting committee for its failure to implement improvements.128 Although attendants regularly complained about their work conditions, they were reluctant to complain about their risk of injury. This may have been because they realised that sickness was antithetical to the qualities of physical strength perceived as integral to their job. The prospect of claiming a pension was also an important motivation. By 1896, more than half of the male attendants had worked at the CLA ‘for many years’.129 CLA nursing staff tried to endure ill-­health, not to signify devotion to duty but to accrue long periods of service to qualify for a pension. It was only when the visiting committee proposed to raise the entitlement to a pension, after fifteen years of service, from the age of fifty to fifty-­five, that attendants complained about their risk of injury. All attendants signed a letter highlighting: The dangers that we are daily subjected to, the most trying, troublesome, unfortunate class of creature that we have to deal with in the execution of our duty, the unhealthy disagreeable, injurious things we have to contend with daily. That Mrs Pyder, (a recently retired nurse) after nearly twenty years service, only enjoyed her allowance for a short time when she returned as a patient and died eight days after admission; this we venture to say, tends to show that we are subject to injury of mind, as well as health, through being confined with the patients for such long periods of time. Also, that several other attendants have received personal injury in the execution of their duty; consequently, they have completely broken down shortly after being superannuated.130

On receipt of this letter, the visiting committee agreed to return to the original pension arrangements. The case of Pyder, cited by the attendants as an example of a nurse who suffered some form of mental illness shortly after retiring, is an indication of the degree of mental strain CLA nursing staff felt. The idea that asylum attendants risked their own sanity through close and prolonged contact with insane patients was taken up by several correspondents to the Lancet during the 1890s as part of a campaign to improve work conditions.131 34

‘To help a million sick’

Claims that asylum nurses were at high risk of mental illness were undermined by the Lunacy Board’s research in 1906, which found the incidence of lunacy among asylum staff lower than in the general population. Fifty-­two attendants out of a total of 10,100 were diagnosed with lunacy during 1906, a figure the Board described as ‘unacceptable considering that attendants were selected for their physical and moral fitness’. However, the Board noted the omission of the ‘frequent number of temporary mental breakdowns’ from these figures.132 At the management level of the CLA, there was very little broad discussion by Adams or the visiting committee as to what caused nurses’ ill-­health. This does not necessarily mean that health issues were misunderstood, but it does imply that they were neglected. The asylum was concerned with its financial responsibilities toward its employees and the need to protect and limit its financial commitments. For example, when attendant Samuel Solomon died of typhoid fever with pneumonia in 1898, the committee decided that it had been ‘contracted out of the asylum’. This is surprising considering that another attendant, William Hill, was also ill with typhoid at the time.133 Anthony Wohl suggests that the presence of typhoid fever served as ‘a barometer of inadequate water supplies and sewerage’:134 an admission of responsibility might have forced the visiting committee to commit to expensive improvements to the asylum’s infrastructure. In another case, an attendant’s behaviour changed significantly following a head injury received at work. He was suspended for ‘indecently exposing himself to children in the asylum grounds and making indecent motions to female patients’.135 Disinhibited sexualised behaviour is common following a traumatic brain injury. The asylum did not consider itself responsible for the attendant’s head injury and did not offer any financial help toward his treatment or pension, much to the chagrin of his previous employer, Bodmin Workhouse, who wrote and complained that the asylum had failed its employee.136 In 1911, a Select Committee, stimulated by proposed amendments to the Asylum Officers’ Superannuation Act 1909, acknowledged the inherent health risks of asylum nursing but no action was taken. The committee heard from twenty witnesses, most of who were either medical superintendents or members of the Lunacy Commission. 35

Who cared for the carers?

Only two asylum attendants were called. All agreed that asylum staff, particularly in acute wards, faced considerable danger from attack. Marriot Cooke, medical superintendent of the Wiltshire County Asylum and committee member, argued that a reduction in working hours would attract better-­ quality attendants whose ‘natural’ intelligence and tact might reduce this risk by establishing better relationships with patients. However, the risk of employing more intelligent men, according to Cooke, was that the incidence of nervous b ­ reakdowns would rise. Intelligence was associated with emotional sensitivity as a result of a middle-­class education. Cooke considered less educated, working-­class men more able to withstand the type of work.137 The committee concluded that: No-­one will deny the special stress and strain of asylum service. Much of the work is tedious, monotonous, wearing, not free from indignities and some personal risk and … may well constitute an excessive strain.138

The term ‘stress’ was frequently coupled with ‘strain’ in the early twentieth century, a reflection of its engineering roots.139 The select committee recommended a seventy-­hour week and a lowering in the retirement age of women. These recommendations were not ­legislated, primarily because of a lack of parliamentary time.140 Conclusions The political question of nurse registration and cultural notions of class and gender significantly shaped voluntary hospital matrons’ attitudes toward nurses’ ill-­ health. The question of nurses’ sickness attracted significant political and newspaper interest in 1890 and was used to justify changes to the nurse’s role. Not only were notions of gender and class used to support nurses’ case for professional status but their relationship to nurses’ health helped define the boundaries of the new nurse’s role. National debates about the organisation of nursing affected the ordinary nurse’s experience of sickness, an experience that differed significantly between voluntary hospitals and between voluntary hospitals and asylums. This difference can be explained by individual matrons’ political views about nurse registration and their power to influence nursing policy. The geographical location of hospitals also seems to have played a part: 36

‘To help a million sick’

certainly, Cornwall’s rural isolation explains the CLA matrons’ lack of participation in nurse registration but asylum nursing’s distinct and different culture was also an important factor. A lack of alternative employment meant nurses were prepared to tolerate ill-­health and poor work conditions. In contrast, The London Hospital was a metropolitan teaching hospital with a prestigious reputation and a ready supply of recruits. This chapter concludes that nursing politics, gender and class were more important than geography in the ­management of nurses’ occupational health in this period. Expectations that nurses would subordinate their own health needs to those of their patients or their employing hospital placed unrealistic demands on nursing staff and made discussion of health issues a sensitive topic, shrouded by suspicion. Luckes clearly cared about nurses’ health and made significant improvements to working conditions, but she also attached importance to a nurse’s ability to endure hardship and discipline as demonstrating commitment. With hindsight, her disregard of nurses’ health problems seems, at times, unsympathetic and coldhearted, but one must understand that her attitude was formulated by her determination to raise the occupation’s standards without an externally imposed set of regulations. The importance attached to the concept of self-­sacrifice varied between voluntary hospitals and between hospitals and asylums. For anti-­registrationists like Luckes, it was an unwritten code of behaviour that was used to organise an unregulated profession and acted as a carrot and stick policy. It not only was a goal to aspire to but also implied a threatened penalty for those unable to live up to the ideal. Nurses’ sickness at The London Hospital seems to have often been discussed in terms of a character failure, but this point is difficult to prove. The notion of self-­sacrifice was less important at the SDEC; Hopkins supported nurse organisations promoting an autonomous, independent and regulated profession. The BNA considered nurses’ illness an almost inevitable consequence of nursing and planned to offer convalescence treatment and financial aid to sick nurses once its membership increased. Hopkins adopted a similar pragmatic attitude and did not interpret illness as a character flaw or as a sign of a lack of vocation, treating it without suspicion. The untrained CLA asylum matrons did not aspire to the vocational ideology of the anti-­ registrationists or the professional standards set by pro-­registration 37

Who cared for the carers?

nursing organisations. Medical superintendent Adams regulated discipline and the visiting committee treated nurses as employees rather than members of a profession. Nurses aspired to accrue long periods of service, tolerating ill-­health to qualify for a pension. In contrast to The London Hospital, where the onus of responsibility for nurses’ sickness was placed on the nurse herself, the asylum was concerned with its financial responsibility toward its employees’ health and the need to protect and limit its financial commitments. Matrons’ powers to influence occupational health care varied between hospitals and shifted over time within individual institutions. Doctors played a key role, and their support dictated, to some degree, the amount of power matrons enjoyed. The London Hospital medical staff supported Luckes’s powerful position as independent manager of the nursing department: the majority shared her political viewpoint against nurse registration, and also the idea that the hospital’s system of nurse discipline should incorporate nurses’ health. Luckes increased her authority and power to influence policy by publishing her ideas about nursing practice and improving nurse education. Nurse education and training were key to matrons’ authority, which depended on training producing good standards of nursing care. Once standards slipped, so doctors exerted their own authority. At the CLA, untrained matrons had little power over nursing policy. Class emerges as an important theme in perceptions of nurses’ health in the late nineteenth century. Debates about nurses’ health, class and professional status were important in establishing the new nurse’s role. Luckes, like many commentators and actors considering nurse registration in this period, perceived middle-­class women to have different physical and mental health needs from working-­class women and used these ideas to support her argument for changes to nurses’ work conditions. Middle-­ class women were generally perceived as less physically robust and with specific requirements to maintain their mental health. For these reasons, some commentators advocated that the new nurse perform managerial tasks and patient care rather than menial cleaning duties. Although the campaign for professional status created the impression that nursing was a middle-­ class occupation, my research supports the idea that nursing was a socially mixed occupation. Further prosopographical research is needed on class background at the case study institutions. 38

‘To help a million sick’

One explanation of why the state failed to regulate nurses’ work conditions in this period could be government’s refusal to acknowledge the health risks attached to middle-­class women’s work. This refusal may have been compounded by nurse leaders’ reluctance to jeopardise their recruitment campaign by drawing attention to middle-­class women’s alleged vulnerabilities. Asylum nurses were predominately drawn from working-­ class backgrounds and, as members of a poorly paid and low-­status occupation, they, and their employers, often ignored their occupational health problems. This situation changed during the First World War when nurses could no longer ignore the dreadful impact of poor work conditions on their health. Notes 1 Pall Mall Gazette (7 September 1890). 2 A shorter version of this chapter appeared in Nursing History Review, 20 (2012), 14–45. 3 Select Committee of the House of Lords on the Metropolitan Hospitals, Report of the Select Committee of the House of Lords on the Metropolitan Hospitals, Provident and Other Public Dispensaries and Charitable Institutions for the Sick Poor, 1890 (392), XVI.1. Chaired by Lord Sandhurst (hereafter referred to as the Sandhurst Report). 4 Sandhurst Report, pp. 294–6. 5 Ethel Gordon Fenwick (née Ethel Gordon Manson). Jane Brooks and Anne Marie Rafferty argue that, although most history of nursing texts refers to Gordon Fenwick as Mrs Bedford Fenwick, she continued to use Gordon Fenwick in her official capacity after her marriage, except as editor of the British Journal of Nursing when she used Mrs Bedford Fenwick. See J. Brooks and A. M. Rafferty, ‘Dress and distinction in nursing’, Women’s History Review, 16:1 (2007), 41–57. 6 B. Abel-­Smith, A History of the Nursing Profession (London: Heinemann, 1960), p. 9; R. Dingwall, A. M. Rafferty and C. Webster, An Introduction to the Social History of Nursing (London: Routledge, 1988), pp. 80–1. 7 A. M. Rafferty, The Politics of Nursing Knowledge (London: Routledge, 1996), p. 51. 8 The Charity Organisation Society was founded in 1869 and attempted to co-­ ordinate the work of charitable institutions and the Poor Law. A. E. Clark-­ Kennedy, The London: A Study in the Voluntary Hospital System (London: Pitman, 1963), pp. 104–5. 9 The Hospital (19 July 1890); Pall Mall Gazette (7, 11, 16 September 1890).

39

Who cared for the carers? 10 Pall Mall Gazette (7 September 1890). Other headliners included ‘Does the London Hospital sweat its nurses’ (13 September 1890); ‘Saints or sweaters?’ (25 September 1890); ‘Deaths traps for nurses’ (29 September 1890). 11 Abel-­Smith, A History of the Nursing Profession, p. 61; Rafferty, The Politics of Nursing Knowledge, p. 94. 12 Sandhurst Report, p. 473. 13 BMJ (13 September 1890), 646. 14 The Royal London Hospital (hereafter RLH), LH/A/17/49, Report of the House Committee on the Allegations Which Have Been Recently Made Against the Nursing Department, 3 December 1890. 15 Sandhurst Report, p. 308; p. 313. 16 Ibid., p. 318. 17 Clark-­Kennedy, The London, pp. 94–5. 18 Sandhurst Report, p. 410. 19 E. Luckes, Lectures on General Nursing: Delivered to the Probationers of The London Hospital Training School for Nurses (London: Kegan Paul, Trench Trubner, 1888). 20 Ibid., p. 278. 21 Abel-­Smith, A History of the Nursing Profession. 22 A. Summers, ‘The mysterious demise of Sarah Gamp: the domiciliary nurse and her detractors, c. 1830–1860’, Victorian Studies, 32:3 (Spring 1983), 362–86. Sarah or Sairey Gamp was a nurse in Charles Dickens’s novel Martin Chuzzlewit (1843–44). Dissolute, sloppy and generally drunk, she became the stereotype of the untrained early Victorian domicilary nurse. 23 S. Hawkins, Nursing and Women’s Labour in the Nineteenth Century: The Quest for Independence (Abingdon: Routledge, 2010), p. 6. 24 RLH, LH/N/1/2, The London Hospital Register of Nurse Probationers, April 1884 – August 1888, p. 227. 25 Sandhurst Report, p. 402. 26 Ibid., p. 308. 27 Ibid., p. 309. 28 Ibid., p. 410. 29 Ibid., p. 313. 30 Ibid., p. 319. 31 Ibid. 32 RLH, LH/A/17/49, Report of the House Committee. 33 Sandhurst Report, p. 476. 34 Ibid., p. 329; p. 397; pp. 440–59; p. 476. 35 Ibid., p. 397. 36 Ibid., p. 329. 37 Ibid., p. 329; p. 447. 38 Ibid., p. 202; p. 209; p. 374. 39 Clark-­Kennedy, The London, p. 105.

40

‘To help a million sick’ 40 Sandhurst Report, p. 307; p. 314; p. 320. 41 RLH, LH/N/1/3, The London Hospital Register of Nurse Probationers, July 1888 – September 1891, p. 230. 42 Ibid. 43 Ibid., p. 320. 44 Ibid., p. 242. 45 RLH, LH/N/5, Official Ward Book, 1901. 46 RLH, LH/A/5, The London Hospital house committee minutes, 8 October 1889. Luckes reported that ‘nursing work is extremely heavy and that a large number of nurses were unwell’. 47 Septic fingers were infected hands or fingers believed to be caused by a germ or ‘poison’ gaining entry into the hand. It was the third most common disorder, following tonsillitis and influenza among probationers at the SDEC between 1903 and 1919. Sandhurst Report, p. 408; Plymouth and West Devon Record Office (hereafter PWDRO), 1490/24, SDEC Register of Nurses, 1903–23. 48 BMJ (13 September 1890). 49 M. Worboys, Spreading Germs: Disease Theories and Medical Practice in Britain 1865–1900 (Cambridge: Cambridge University Press, 2000), p. 3. 50 Luckes, Lectures on General Nursing, pp. 279–99. 51 Sandhurst Report, p. 402. 52 BMJ (13 September 1890), 646. 53 Nursing Record and Hospital World (28 October 1893), 202. 54 Sandhurst Report, p. 313; p. 327. 55 Worboys, Spreading Germs, p. 39. 56 Sandhurst Report, p. 329. 57 RLH, LH/A/5, The London Hospital house committee minutes, 22 October 1889. 58 Sandhurst Report, p. 392. 59 RLH, LH/A/26/5, Luckes, ‘Trained nursing at The London Hospital’, p. 303. 60 A. Summers, Angels and Citizens: British Women as Military Nurses 1854– 1914 (London: Routledge, 1988), pp. 1–9; Rafferty, The Politics of Nursing Knowledge, p. 25; C. Davies, Gender and the Professional Predicament in Nursing (Buckingham: Open University Press, 1995), p. 58; P. D’Antonio, ‘Revisiting and re-­thinking the rewriting of nursing history’, Bulletin of the History of Medicine, 73:2 (1999), 271. 61 RLH, LH/N/17/49, Luckes, Report of the House Committee, 3 December 1890. 62 RLH, LH/A/26/5, Luckes, ‘Trained nursing at The London Hospital’, p. 303. 63 Dingwall, An Introduction to the Social History of Nursing, p. 58. 64 Lancet (26 July 1890), 194. 65 Sandhurst Report, p. 452. 66 Ibid., p. 456.

41

Who cared for the carers? 67 Dingwall et al., An Introduction to the Social History of Nursing, p. 58. 68 More detailed study is needed of nurses’ class background to reveal the social origins of nonpaying probationers at The London Hospital. Sandhurst Report, p. 398. 69 Hawkins, Nursing and Women’s Labour, p. 174. 70 RLH, LH/A/17/48, Luckes, letter to hospital committee, 20 October 1888. 71 RLH, LH/A.26/5, Luckes, ‘Trained nursing at The London Hospital’, p. 292. 72 Sandhurst Report, p. 335; p. 379. 73 Ibid., p. 336. 74 The Hospital (19 July 1890), 240. 75 Pall Mall Gazette (11 September 1890). 76 Lancet (26 July 1890), 194. 77 Abel-­Smith, A History of the Nursing Profession, p. 17. 78 The Hospital (16 August 1890). 79 Sandhurst Report, p. 407. 80 See A. Richardson, Love and Eugenics in the Late Nineteenth Century: Rational Reproduction and the New Woman (Oxford: Oxford University Press, 2003); L. Hughes, ‘“A club of their own: the literary ladies”, new women writers, and fin-­de-­siecle authorship’, Victorian Literature and Culture, 35 (2007), 233–60; M. Beamont, ‘A little political world of my own: the new woman, the new life and new amazonia’, Victorian Literature and Culture, 35 (2007), 215–32. 81 Letter from Herbert Yatman, The Times (30 July 1890), 13. 82 PWDRO, 606/1/7, SDEC general committee minutes, 14 August 1903, p. 225. 83 J. Grier and D. Mole, Brief History of Plymouth Hospitals (Plymouth: The Old Plymouth Society, 2004), p. 24. 84 B. Abel-­Smith, The Hospitals 1848–1948 (London: Heinemann, 1964), p. 68; A. Witz, Professions and Patriarchy (London: Routledge, 1992), p. 140; S. Wildman and A. Hewison, ‘Rediscovering a history of nursing management: from Nightingale to the modern matron’, International Journal of Nursing Studies, 46 (2009), 1650–61. 85 Nursing Record and Hospital World (14 June 1888), 127. 86 PWDRO, 606/1/3, SDEC general committee minutes, February 1894–97. 87 Rafferty, The Politics of Nursing Knowledge, p. 63. 88 Nursing Record and Hospital World (12, 19 July 1888); (4 July 1889). 89 Ibid. (4 July 1889), 18–19. 90 E. Luckes, What Will Trained Nurses Gain by Joining the British Nurses’ Association? (London: J. and A. Churchill, 1889). 91 Rafferty, The Politics of Nursing Knowledge, p. 64. 92 Nursing and Hospital World (21 July 1894), 51. 93 Ibid. (22 October 1898), 330. 94 PWDRO, 606/1/1, SDEC general committee minutes, 1 March 1886.

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‘To help a million sick’ 95 C. Wood, ‘The training of nurses for sick children’, Nursing Record and Hospital World (6 December 1888), 507. 96 PWDRO, 606/1/1, SDEC general committee minutes, 26 August 1889. 97 PWDRO, 606/1/2, SDEC general committee minutes, 1 July 1890, p. 8. 98 PWDRO, 606/1/7, SDEC general committee minutes, 15 March 1904, p. 340. 99 PWDRO, 606/1/2, SDEC general committee minutes, 18 October 1898. 100 PWDRO, 1490/24, SDEC Register of Nurses, 1903–23. 101 Ibid., 1903–19. 102 Ibid., 1903–23. 103 PWDRO, 606/1/7, SDEC general committee minutes, 23 September 1909. 104 Western Daily Mercury (5, 7, 10, 14 February 1904). 105 Ibid. (7 February 1904). 106 S. McGann, ‘The development of nursing as an accountable profession’ in S. Tilley and R. Watson (eds), Accountability in Nursing and Midwifery (Oxford: Blackwell Science, 2004), p. 15. 107 PWDRO, 606/1/18, SDEC house committee minutes, 24 March 1905, p. 159. 108 Ibid., 7 June 1905. 109 Ibid., 23 March 1904, 2 June 1905. 110 Ibid., 12 September 1905. 111 R. Duncan, ‘Case studies in emigration: Cornwall; Gloucestershire and New South Wales, 1877–1886’, Economic History Review, 16:2 (1963), 272–89. 112 G. Burke and P. Richardson, ‘The profits of death: a comparative study of miners’ phthisis in Cornwall and the Transvaal, 1876–1918’, Journal of Southern African Studies, 4:2 (April 1978), 147–77. 113 Cornwall Record Office (CRO), HC1/1/6, Report of the Lunacy Commissioners 1896. 114 J. Melling and B. Forsythe, The Politics of Madness: The State, Insanity and Society in England, 1845–1914 (Abingdon: Routledge, 2006). 115 P. Nolan, A History of Mental Health Nursing (London: Chapman & Hall, 1993), p. 61. 116 F. R. Adams, ‘From association to union: a professional organisation for attendants, 1869–1919’, British Journal of Sociology, 20:1 (March 1969), 11–26. 117 Nolan, A History of Mental Health Nursing, p. 69. 118 Nursing Record and Hospital World (12 December 1896). 119 Ibid. (6 February 1897), 114. 120 CRO, HC1/1/1/15, Cornwall Lunatic Asylum Visiting Committee Minutes (hereafter CLAVC), 25 August 1913, p. 70. 121 Dingwall et al., An Introduction to the Social History of Nursing, p. 126. 122 Nolan, A History of Mental Health Nursing, p. 72. 123 CRO, HC1/1/1/6, CLAVC minutes, 26 February 1894, p. 329.

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Who cared for the carers? 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140

CRO, HC1/1/1/7, CLAVC minutes, 28 September 1896. CRO, HC1/1/1/6, CLAVC minutes, 27 October 1890, p. 160. CRO, HC1/1/1/7, CLAVC minutes, 27 June 1898. Ibid., 24 June 1889, 9 June 1891, 25 July 1892; 24 May 1897; 13 June 1903. C. T. Andrews, The Dark Awakening: A History of St. Lawrence’s Hospital, Bodmin (London: Cox Wyman, 1978), pp. 91–3. CRO, HC1/1/1/6, Report of the Lunacy Commissioners, 1896, p. 13. CRO, HC1/1/1/6, Letter from attendants to the visiting committee, CLAVC minutes, 27 December 1894. Lancet (9 August 1890), 318. Report and Special Report on the Asylum Officers (Employment, Pensions and Superannuation) Bill together with the proceedings of the committee, minutes of evidence and appendix (London: HMSO, 1911). CRO, HC1/1/1/7, CLAVC minutes, 26 September 1898. A. S. Wohl, Endangered Lives: Public Health in Victorian Britain (London: J. M. Dent, 1983), p. 127. S. Bezeau, N. M. Bogod and C. Mateer, ‘Sexually intrusive behaviour following brain injury: approaches to assessment and rehabilitation’, Brain Injury, 18:3 (March 2004), 299–313. CRO, HC1/1/1/6, CLAVC minutes, 26 February 1894, p. 329 Ibid., pp. 4–5 Report and Special Report on the Asylum Officers, p. 4. C. L. Cooper and P. Dewe, Stress: A Brief History (Oxford: Blackwell, 2004), p. 9. M. Carpenter, Working for Health, pp. 50–1.

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2

The First World War and nurses’ choice of occupational representation

In 1918, Francis Dudley, medical superintendent of the Cornwall Lunatic Asylum, reported that rising sickness levels among the nursing staff had contributed to a rapid uptake in trade union membership and strike action. According to Dudley, the previous year had been ‘an exceptionally trying year for the staff’ resulting in the deaths of two attendants and five nurses from infectious diseases: temporary attendant Matthews and nurses Symons, Vague and Launder from typhoid fever; attendant French and nurse Cooksly from phthisis and nurse Scantlebury from influenza. All were under the age of thirty. Dudley concluded that the rising mortality rate plus the loss of regular staff to military service ‘caused the unrest on the female side, which reached a climax in October’ when fifty of the seventy female nursing staff went on a five-­day strike.1 Male attendants chose not to join the strike although seventy-­two of a total of seventy-­five took up union membership following an appeal to support their female colleagues.2 This chapter examines the extent to which ill-­health shaped nurses’ choice of occupational representation during the First World War. As mentioned in the introduction, Christopher Hart identifies trade unionism with working-­class male attendants and the College of Nursing with middle-­class female voluntary hospital nurses.3 His argument that gender and class explains the different routes of representation is based on the notion that middle-­class women were more likely to adhere to the vocational value of self-­sacrifice, rising above material distractions such as pay and conditions of service.4 Men, on the other hand, Hart suggests, often had a background of work experience elsewhere and ‘wages were of greater importance 45

Who cared for the carers?

as they had families to support’.5 To date, the question of whether the health of nurses influenced choices of representation has been neglected. To set this choice in context, the chapter starts by examining the ways the First World War prompted interest in the health of other groups of workers. It then gives a brief history of the National Asylum Workers’ Union and the College of Nursing before focusing on the impact of the war on nurses’ health and choice of representation at the Cornwall Lunatic Asylum and the South Devon and East Cornwall Hospital. Occupational health and the First World War Prior to 1914, occupational health was neglected by the majority of British managers and employers, who were concerned only with staying within the legal limits of the Factory Acts.6 However, the First World War brought the debate on industrial health into the public arena. By the summer of 1915, the British war effort was struggling as the productivity of munitions workers declined as the result of chronic fatigue. The government set up the Health of Munitions Workers Committee (HMWC) to investigate the relationship between industrial health and efficiency. The committee found a correlation between excessive working hours, poor general work conditions and productivity levels. This was the first time that factors such as nutrition and fatigue were considered as being as important in the production of occupational illness as factors produced by the materials being handled.7 The government acted on a number of the committee’s recommendations including a reduction in working hours and the abolition of Sunday working.8 Nurses were appointed to munitions factories and their roles included basic first aid and health screening as well as preventing health problems by promoting healthy living. The munitions factory at Woolwich, for example, employed a matron, four nursing sisters and a staff of nursing orderlies.9 In 1917, the HMWC was disbanded and the Industrial Health Research Board (IHRB) was set up to investigate industrial health and fatigue in a much broader group of workers. J. C. Bridge, a factory medical inspector during the war and later Chief Inspector of factories, argued that ‘the [First World] War period had … a very great influence on industrial medicine. It showed 46

The First World War

that the health of the workers was of great economic value and that a worker maintained in good health was of prime importance.’10 The lesson of the war may have been less durable than Bridge supposed, for, in 1919, the Lancet compared the situation of industrial medicine in Britain unfavourably with that in the United States.11 Although some firms appointed whole-­or part-­time medical officers after the war, their numbers were small.12 Concerns over the physical condition of the working classes, which had been aggravated by the recruitment experiences of the Boer War, were not allayed by the experiences of medical boards assessing the physique of recruits after the introduction of conscription in 1916. Despite the falling mortality rate in the general population, these experiences suggested that there had been little real improvement in the health of the poorer classes since 1900.13 Working-­class asylum nurses were therefore more likely to have been in poorer physical shape and more vulnerable to illness than middle-­class voluntary hospital nurses. The National Asylum Worker’s Union The National Asylum Workers’ Union (NAWU) was formed in 1910 by a group of charge attendants from five Lancashire asylums. These men were frustrated by the Asylum Officers’ Superannuation Act in 1909 which intended to improve work conditions with the introduction of a pension scheme on a contributory basis but resulted in a wage cut for many attendants who had previously enjoyed non-­contributory arrangements. This, according to Dingwall et al., ‘crystallised many of the attendants’ dissatisfaction with low pay, long hours and poor working conditions’.14 Negative financial effects of the 1909 Act prompted asylum nurses to identify with the rising working-­class movement during the Edwardian period. From 1910 to 1913, retail prices rose faster than wages and, as unemployment fell, miners, dockers, seafarers and transport workers adopted more militant attitudes.15 The onset of war in August 1914 led to a general decline in industrial and political conflict as the bulk of the labour movement, including the NAWU, came out in support of the war effort. The NAWU’s main concern during the war was reducing the 47

Who cared for the carers?

working week to sixty hours but it also prioritised the protection of male attendants’ jobs and wages. Asylums would be reluctant to employ returning male military personnel at their former rates of pay, the Union reasoned, once they realised they could save money by employing women, at a lower rate of pay, to care for male patients.16 Traditionally, asylums operated a strict segregation policy, with male attendants caring for male patients in a separate part of the asylum to female patients who were cared for by female nurses. The shortage of  male attendants during the war prompted debate within the pages  of the Union’s magazine, and the nursing press, about the ­feasibility of women caring for male patients. The debate focused on female asylum nurses’ sexuality. Opponents to the proposition based their argument around the notion that male patients posed a threat to nurses’ virginity: for example, one correspondent suggested that ‘losing their modesty was something lost which could never be regained and no woman should ever be called upon, unnecessarily to make such a sacrifice’.17 The duties involved in caring for male patients, another contributor suggested, ‘were repellent to the finer instincts of chaste womanhood … the employment of women has hitherto, for the soundest medical reasons been debarred’.18 A soldier and former attendant combined the language of sexuality and the notion of the male breadwinner to voice his opposition: women, he argued, were ‘robbing [men] of employment’ and ‘our kiddies of their bread and butter, by doing our work at a cheaper rate than that for which a woman’s soul and honour can be bought’.19 This was a shocking juxtaposition of degradation and innocence, conflating connotations of prostitution with the purity and innocence more normally associated with nurses. To substantiate its support for their male members, the NAWU promoted the idea that women made poor trade union members. Explaining the low uptake in female union membership in the early years of the war, the Reverend H. M. S. Bankart, the Union’s first secretary and magazine editor, suggested that women ‘as a class’ lacked the unity to become good union members and were therefore responsible for their poor work conditions: ‘women are the most sweated, defenceless and disfranchised drudges of the industrial market, because they are unorganised’.20 Women were less committed than men, Bankart argued, ‘it was a fairly easy matter to rouse them to a 48

The First World War

pitch of enthusiasm but a more difficult one to keep them at it’.21 He criticised women for being ‘easily cowed and notoriously ungrateful for benefits the Union fought for’. Men, on the other hand, were described as the ‘backbone of the Union’ and credited with raising the status of asylum nursing.22 As we will see, the NAWU’s attitude towards women union members had changed by 1918. The College of Nursing The College of Nursing was set up in 1916 as a limited company by Sir Cooper Perry (a member of the Army Medical Board and Medical Superintendent of Guy’s Hospital), Dame Sarah Swift (Chief Matron of the British Red Cross Society and formerly Matron of Guy’s Hospital) and the Honourable Arthur Stanley (Chairman of the Joint War Committee of the British Red Cross Society and Order of St John and, from 1917, treasurer of St Thomas’s Hospital).23 It was formed partly in response to the problem of the multiplicity of qualifications held by the growing number of ‘nurses’ but also as a way of controlling the nurse labour market. From the outset, professionalism was central to the College’s strategy: its objectives were to promote education, standardise the nursing curriculum, recognise approved nursing schools and maintain a nurse register.24 Its Articles of Association prevented it from imposing trade unionism on its members or financially supporting other trade unions.25 Its approach combined the professional status of the Royal Colleges of Medicine with the representative function of the British Medical Association. Often perceived as exclusive, it attracted fewer than half the country’s nurses. Its leaders tended to be hospital matrons, and rank and file members were not directly represented on its council or active at local levels. This chapter, as I have explained, focuses on nurses’ attitudes towards occupational representation between 1914 and 1919. One could argue that it is unfair to compare the tactics of the College with that of the NAWU. After all, the College was a much more recent organisation which had hardly got off the ground by the end of the war. On the other hand, it is still worth exploring the College’s early attitude towards nurses’ pay and work conditions to demonstrate how far its attitude changed in the 1920s and beyond. 49

Who cared for the carers?

In its early years, the College considered trade unionism incompatible with nursing. It took up position as the patient’s advocate arguing that ‘the hard and fast rules required’ under trade unionism cannot be applied to those engaged in nursing without detriment to the patients under their care. The aim of the College, while endeavouring to improve the conditions of nursing is, at all times to safeguard the standard of nursing of the sick.26

Despite the increasing secularisation of nursing, the College’s ethos was framed around notions of morality. On the one hand, the College embodied a process of modernisation, with its emphasis on training and examination, yet on the other, it promoted the idea that nurses were motivated by moral ideals rather than material rewards. It encouraged its supporters to see nursing as a vocation and intangible goals as their reward. A letter from a College member to the Nursing Times, in 1919, implied that difficult work conditions and low pay were a necessary deterrent to weed out unsuitable applicants: It is doubtful if high salaries attract the best type of men or women into any profession; especially in the nursing profession we only want women who are attracted by such a real love for the work that salary is a secondary consideration. We do not want women whose first thought is what hours they will have to work and what salary they will receive, for no amount of training will ever make them nurses.27

The College was vehemently opposed to strike action on the grounds that it would betray patients’ ‘sacred trust’ in nurses.28 A clear difference between the ethos of the NAWU and the College of Nursing emerged in 1917. The College stipulated that its members should be general trained nurses and was concerned with education and training whilst the NAWU focused on improving asylum nurses’ work conditions. Our next step is to examine whether these objectives, or other factors, influenced CLA and SDEC nurses’ choice of representation during the war. The Cornwall Lunatic Asylum Eight months after the outbreak of the First World War, dreadful work conditions at the CLA had a detrimental impact on the health of nurses. A rapid increase in patient numbers placed heavy demands 50

The First World War

on a depleted staff, since many had been called up for military service. In March 1915, 226 pauper patients were transferred from Bristol Asylum to make room for wounded soldiers. The CLA had accommodation for 1,000 patients but numbers rose to 1,226.29 Initially patients slept on the ward floors whilst the War Office was petitioned to supply bedsteads. Out of a staff of seventy-­two male attendants, twenty-­seven had already left for military duty by July 1915, leaving a significant gap in the number of those with experience. Their places were filled by retired attendants, ‘men above military age’ and ‘married men with families’,30 the latter two groups having no previous experience of asylum work.31 CLA nurses continued to be drawn from the working classes during the war: for example, attendant George White had previously worked as an outfitter’s apprentice and his sister was a servant;32 Albert Julian’s father was a shoemaker and his brother was a grocer’s assistant.33 Medical superintendent Dudley was initially optimistic about the quality of temporary attendants and told the visiting committee that the asylum was ‘unusually lucky’. However, by 1915, difficulties recruiting ‘suitable substitutes’ prompted him to lobby the Parliamentary Recruiting Committee to refrain from calling up any more staff.34 An initial promise was unfulfilled and the number of attendants called up rose from thirty-­four in 1915, to forty-­three in 1916, to forty-­nine in 1917.35 The introduction of temporary attendants brought with it an increase in male staff turnover. Prior to 1915, male attendants formed a stable workforce, prepared to tolerate poor work conditions and ill-­health in the hope of receiving a pension. However, in 1916, one-­fifth of the male staff resigned or was found unsatisfactory.36 In an attempt to encourage staff to stay, the visiting committee introduced a war bonus for head attendants, head nurses and married male attendants in May 1915, eight weeks after the arrival of the Bristol patients. It was given ‘in consideration of the increase in patient numbers’, the committee explained, ‘and the extra cost of living caused by the war’.37 Male staff received a higher bonus than female nurses, reinforcing the notion of the male breadwinner. The chief male attendant received an increase of £9, taking his salary to £99 annually. Married male attendants received two guineas a week, so they were now paid between £29 and £52 depending on years of 51

Who cared for the carers?

service; and the two assistant head nurse’s wages were raised by £1 to between £19 and £31. Unequal pay continued throughout the war: whilst all male attendants were given the war bonus in 1916, female staff had to wait until November 1918.38 Although one might assume that unequal pay contributed to the upsurge in female nurses’ militancy in October 1918, it was not listed in the women’s grievances. Dudley retained his authoritarian style of discipline despite the staff shortages. He did not contemplate relaxing discipline as a way of attracting new recruits or improving retention rates. The ability to obey orders, according to Dudley, determined whether a nurse proved satisfactory. In the first two years of the war, nurses Pitts, Penelly, Scutlebury and Kendall were discharged for failing to ‘peg the clock’ three times in a row on night duty.39 A system of ‘peg clocks’ was used to prevent staff sleeping on night duty; each nurse would insert and turn a key every hour and the clock would record the time pegged. Nurse Scutlebury’s appeal that she had been unable to peg the clock because she was with ‘a troublesome patient’ failed because she had not recorded this information at the time in a book situated next to the clock.40 Nurses’ work conditions deteriorated because the increase in patient numbers meant an increased workload, a rise in working hours and the cancellation of leave. Nurse Clara Williams joined the CLA on 22 October 1914 and went ‘absent without authority’ five months later, on 29 March 1915. In a letter to the visiting committee, she explained that she left because ‘she did not feel well’ and ‘had repeatedly asked for three days leave but had been told that she could not be spared’. Throughout her period of employment she had slept in a patient’s room, which she described as uncomfortable, without a lock and giving her no privacy. During a month of night duty in February 1915, according to Williams, matron had persistently ­interrupted her daytime rest.41 The increased workload resulted in an immediate rise in staff sickness that continued until the end of the war. Prior to the arrival of the Bristol patients, in 1914 and the first quarter of 1915, the average sickness rate was two nurses per month.42 Four weeks after the arrival of the Bristol patients, in April 1915, the number of nurses on sick leave rose to sixteen female nurses and eleven attendants.43 Numbers remained high until 1918. For example, in March 1916 ten staff were 52

The First World War

on sick leave, rising to eleven in May and to twenty-­six in January 1917.44 Whereas physical injury from violent patients had posed the greatest health risk in the late nineteenth century, the risk during the war was from infectious diseases. For example, three female nurses contracted diphtheria and three nurses scarlet fever in 1915.45 The rise in infectious diseases caused tension between the medical staff and some of the relatives of the diseased staff. The family of nurse Best, who died from diphtheria in 1915, contested her diagnosis, claiming that the cause of death was ‘the sleeping draught of morphia’ given by the medical locum, Dr Alexander. The family dropped the case when Dudley produced evidence of the laboratory analysis of diagnosis. However, the Best family’s criticism of the ways the CLA cared for its sick nurses prompted Dudley to employ two trained general hospital nurses from Plymouth to care for sick staff.46 The arrival of the Bristol patients coincided with a rapid increase in the incidence of dysentery and diarrhoea among staff and patients. Opinions about the cause of asylum dysentery were divided. Harold Gettings, medical superintendent of the West Riding Asylum, Wakefield, suggested that it was not simply overcrowding, as others had suggested: It is not a question of unsanitariness or of overcrowding … or the other factors that have been proposed. They are only side issues, important in their way, but side issues all the same. It is the actual infection that matters; it is the chronic cases, the ‘carriers’, who keep the … infection going … They form the keystone of the problem, and must be detected and isolated before any permanent good can be done.47

Effective methods of infection control were reintroduced to the CLA only in 1918 when patients with dysentery were isolated and attendants given ‘strict injunctions … to personal ablutions and cleanliness’.48 An isolation unit had opened in 1900 but its lack of effectiveness during the war may have been because of a shortage of suitable nurses to staff it, or perhaps the number of infectious cases was greater than its number of beds. For example, there were thirty-­ five cases among patients in 1917, and 163 cases in 1918. The policy of isolating all infectious patients was resumed in 1919 and immediately produced a dramatic reduction in the number of cases of dysentery. Only three cases were recorded in 1919, a fact Dudley attributed to the success of segregation ‘together with improved diet’.49 53

Who cared for the carers?

In 1918, CLA nursing staff experienced a further deterioration in their work conditions. The asylum had introduced food rations in 1916 and again in 1917, when nursing staff were restricted to one pound of meat and half a pound of sugar per week. The quality of ingredients was poor, particularly the flour, and bread was often returned to the kitchen uneaten. Heating was rationed and there was a shortage of water from worn, cracked and leaking pipes. In May 1916 it was estimated that 26,000 gallons per day were lost.50 As a result of an inadequate diet, staff health and patients’ health suffered to the extent that the Board of Control noted, in April 1918, that the ‘health of inmates has latterly been unsatisfactory’ and that a ‘large proportion’ were losing weight.51 In response to nurses’ complaints about the amount and quality of food, the visiting committee agreed to a compensatory weekly grant of 4 shillings to every member of staff.52 Nurses’ anxiety about the risk of illness increased, exacerbated by deteriorating working conditions. A fear of infection and a poor diet caused several nurses to resign. For example, Winifred Waterfield left in July 1918 ‘because the food is not good enough’ and she was ‘afraid of becoming sick’.53 Dudley started dismissing nurses he considered vulnerable to illness. Temporary nurse Richards was asked to leave because Dudley did not consider her ‘strong enough for the work’. Nurses began to leave in groups prompted by minor incidents. In October 1917, for example, five nurses resigned when a nurse was dismissed for pulling a patient’s hair.54 Tensions between senior and junior nursing staff developed partly because of the struggle of day-­to-­day work but also as a result of Dudley’s difficulties in attracting suitable staff. In 1917, a lack of applicants for the assistant matron post forced Dudley on a recruitment campaign in London, visiting general infirmaries to persuade nurses to apply. One nurse agreed to join the CLA but then found another job, another came and went on the same day.55 Helen Jones was eventually appointed in August 1918 and became matron in February 1919 when Margaret Hiney was dismissed. The pattern of employment among senior staff changed. In the nineteenth century, matrons worked at the CLA for decades but periods of employment during the latter stages of the war were much shorter. Elizabeth Taylor was in post for only eighteen months and Margaret Hiney for three years.56 54

The First World War

Hiney was thirty-­three years old when appointed and had previously worked at St Olave Infirmary, a general hospital attached to Rotherhithe Workhouse. During her first few weeks in post she made several immediate changes to long-­standing work practices to which junior nurses objected. These included the cost-­cutting measure of providing material instead of ready-­made uniform. She also tried to establish herself in the role of disciplinarian, taking over from the medical superintendent. She enforced a stricter system of rules, which included moving permanent female night staff on to day duty if they committed a fault at work.57 Although she made positive changes by increasing nurses’ leave to one full day a week, giving nurses two hours free every evening and allocating rooms for recreation when not in use by medical locums, these were overlooked.58 Nurses did not like the change to traditional practices and complained to the visiting committee but without success. Nurse Ethel Dyer, who failed to return to the CLA following annual leave, in July 1918, claiming ill-­health, wrote a letter of complaint to the committee which was dismissed as ‘not based on any reasonable foundation’ with ‘no real cause for complaint’.59 Junior nurses also complained to the NAWU, whose post-­strike analysis of its causes included Hiney’s management style.60 In October 1918, tension between senior and female nurses heightened resulting in a campaign of industrial action. Dudley was convinced that rising levels of nurses’ sickness played an important part in the rapid uptake of union membership and strike action. In his annual report, he explained the roots of the crisis. It has been an exceptionally trying year for the staff, six more of our attendants and three of the artisans were called up for military service. Below strength in all departments, it had to cope with the increased work due to the abnormal amount of sickness involving extra hours of duty under very depressing circumstances. During the year temporary attendant Matthews, nurses H. Symons, E. Vague and O. Launder died of typhoid fever. Attendant French and nurse E. Cooksly of phthisis and nurse R. Scantlebury of influenza. With one exception they were under 30 years of age. These facts coupled with inability to obtain candidates of more mature age, caused the unrest on the female side, which reached a climax in October. The Matron’s health completely broke down in the beginning of November from worry and overwork. She will not be fit for duty for some months.61

55

Who cared for the carers?

Dudley struggled to cope with the high levels of staff illness. Following nurse Launder’s death, he accused the general nurse caring for her of neglect. He claimed that this nurse’s failure to visit Launder between 11 p.m. on 25 June and 6 a.m. on 26 June contributed to her death on 27 June.62 The accused nurse was immediately discharged. The October 1918 strike On 21 October 1918, female nurses’ resentment about their poor work conditions came to a head, resulting in a five-­day strike.63 This was the second strike in a matter of weeks among asylum workers. The first occurred on 4 September 1918 when two hundred attendants from Prestwich Asylum were joined by 449 from Whittingham Asylum.64 The main complaint of the CLA nurses was that their relationship with senior nursing staff had broken down. Further grievances included an eighty-­hour week, no staff bathroom and poor meal facilities where nurses had to wash the utensils left in the mess room and cook their own food in the twenty minutes allowed for meal breaks.65 The appointment of Mrs D. Hawken to the nursing staff on 2 September 1918 stimulated a rapid rise in union membership. Hawken had transferred from the Prestwich Asylum, the location of the first strike. She was an active NAWU member and took up the post of union leader at the CLA. According to an account in the Bodmin Guardian, Hawken had been in Bodmin only four days when nurses began telling her of their grievances and asking why it was that they could not get things changed. They told her how they had asked to see the visiting committee but their request had been refused.66 Over a period of two days, Hawken recruited sixty-­two of the seventy female staff to the NAWU. Problems arose when matron Hiney, aggrieved at this development, banned nurses from wearing their union badges on duty reminding them of the rule forbidding the wearing of jewellery. Hawken’s refusal to remove her badge prompted others to follow her initiative. Articulate and confident, she resisted intimidation by senior nursing staff. The NAWU Magazine alleged that she was held ‘prisoner’ by the matron, overnight, in a disused room ‘until she could be dealt with by the medical superintendent the next day’.67 Dudley dismissed Hawken and the four other 56

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‘ringleaders’ with one month’s notice, without consulting the visiting committee. His refusal to reinstate the five women prompted thirty-­ nine nurses to strike. The acting NAWU secretary, H. Shaw, was sent from Manchester to take charge of the strike and negotiate between the nurses, Dudley and the visiting committee. Dudley maintained that the five leaders had given previous cause for complaint and that all the nurses had broken the rule dictating that no jewellery be worn with uniform. Shaw explained that the Union now had branches in nearly every asylum in the country and that very few of these objected to the wearing of the badge. He contested Dudley’s authority to dismiss nurses without reference to the committee, claiming this was not done in other asylums. He also demanded that all the strikers be ­reinstated with guarantees that they would not be penalised. News of the strike spread to the town, where there was considerable sympathy for the strikers. On 23 October, a public meeting was held at the CLA gates where Hawken gave a ‘scathing exposure of the conditions’ in the asylum and described ‘the treatment she and her fellow workers had received at the hands of the matron, assistant matron and medical superintendent’. By 25 October the number of nurses on strike had risen to fifty, all of who were dismissed by Dudley for ‘insubordination’. The asylum’s Victorian system of discipline was breaking down and only twenty nurses remained on duty.68 The visiting committee’s proposal to allow all but the five leaders to return to work was rejected by the strikers, who paraded banners through the town inscribed with the motto ‘all or none’ in an attempt to encourage public support. Although male attendants did not join the strike, seventy-­two out of a total male staff of seventy-­five took up NAWU membership following a direct appeal from Shaw to support the women.69 Fear of a male attendants’ strike forced the visiting committee to reinstate all the sacked nurses.70 The committee agreed to ‘recognise’ the NAWU in its future negotiations with nursing staff and to allow union badges to be worn but ‘in such a position as not to cause any injury to the patients’. This implied that nurses’ initial insistence on wearing badges had neglected to consider the possible injury they might cause. The visiting committee acknowledged a lack of effective liaison between Hiney and Dudley in the months preceding the strike and resolved in future ‘that all serious cases of neglect 57

Who cared for the carers?

of duty or of improper behaviour on behalf of the asylum staff should be at once reported to the medical superintendent who will deal with the case as he considers necessary’.71 Thus the medical superintendent re-­exerted his power over the nursing staff. At the same time, matron Hiney was given six weeks’ sick leave because of ‘worry and overwork’.72 This was not the end of the matter, and tension between Hiney and the junior nurses continued, following her return to work. The NAWU complained to the Board of Control that she treated ‘the subordinate female staff (the strikers) with absolute lack of courtesy with possible rebellious results’.73 Hiney was given further sick leave after Dr Anderson diagnosed a severe heart complaint and two months later, in January 1919, the visiting committee dismissed her with three months’ notice ‘in view of the medical opinion as to the condition of her heart’.74 It is difficult to know whether it was Hiney’s medical condition or the union’s threat of further strike action that influenced the committee’s decision. Hiney’s attempts to reform the nursing department failed because junior nurses resented the changes to established policies even when some were for their benefit. As a result, senior nurses lost their brief glimpse of power over nurses’ rules and regulations. Although power returned to the medical superintendent, it was now constrained by the NAWU and its ability to enforce a set of minimum standards. As a result of the strike, the visiting committee set about revising staff pay and work conditions. Before the war, male attendants had received £27 per annum rising to £47 after twenty years but, in 1919, this increased to £58 4s for all male attendants. Female nurses had been paid from £15 to £28 after fifteen years but this rose to £33. Other improvements included a reduction in working hours from eighty to sixty-­three ­hours per week including meal times and the introduction of overtime at a rate of time and a half. For the first time, a contract of employment was introduced for new staff to sign after completing a three-­month probationary period. The contract guaranteed the sixty-­three-hour week and the right of complaint. Employees promised to ‘obey the rules of the Asylum’ and ‘to avoid gossiping about its inmates or affairs’.75 As a result, work conditions significantly improved in the immediate post-­war years. The Bristol patients left and, by February 1919, 58

The First World War

the number of patients had been reduced to 1,096. But despite the reduction in workload and a better supply of food, Dudley still considered ‘the health of the female staff unsatisfactory’ in contrast to the ‘satisfactory’ bill of health given to the male attendants.76 In 1919, a nursing subcommittee was set up which instigated improvements to nurses’ living conditions including separate sleeping accommodation away from the wards and a designated wing for staff use with dining and recreation rooms.77 Some nurses still slept on the wards but were provided with separate bathrooms from the patients.78 Despite the disruption caused to the asylum during the strike, Dudley endorsed the Union’s aims in his report of 1918: Though the NAWU has been working for many years it increased its membership to such an extent during the past twelve months there can be very few asylum employees who are not members. The object of this organisation being to improve the condition of asylum workers, the great majority of staff showed their confidence in it by joining in October.79

Following its successful intervention in the CLA strike and its increase of power at local level, the NAWU extended its influence to regional and national policy. In November 1918, Dudley joined a committee of representatives from asylums in the south-­west of England interested in implementing a standardised scale of pay and uniform conditions of service. Shaw participated as the asylum workers’ representative. A schedule of wages, war bonuses and allowances, matching those at the CLA, were set and implemented across the region.80 As a result of its success, the Ministry of Labour declared its interest in the Union as a negotiating body and the Board of Control recognised its potential to improve work conditions.81 The end of the war saw a rapid increase in national NAWU membership, from just under 12,000 in December 1918 to 15,000 by the end of 1919. Membership between the sexes became more evenly spread, with women’s membership reaching 46 per cent of the total.82 Central to its development during this period was its adoption of a National Programme, which included in its wide-­ranging demands a forty-­eight-­hour week, a minimum weekly wage of £3 5s, equal pay for women, state registration for mental nurses, the institution of wages boards and universal recognition of the union as the fit negotiating body by the asylum authorities. The term attendant was 59

Who cared for the carers?

dropped and both men and women became known as mental nurses. The programme was ratified by the branches and presented to the visiting committees of asylums in England and Wales in January 1919.83 In 1919, London County Council called together a Conference of Representatives of Public Asylum Authorities at which Ted Edmondson, President of the NAWU, considered the position of women and equal pay ‘the great stumbling blocks’.84 Because women were subjected to the same ‘stress and strain of work in an atmosphere of lunacy’, Edmondson argued they should be paid equally.85 However, a Joint Conciliation Committee, set up by the NAWU and the ‘authorities to deal with indoor staff’ backed down on demands for equal pay and agreed that female nurses should receive 80 per cent of male rates.86 Although the Union did not succeed in winning its full programme, it established its right to speak as the voice of asylum workers. Its attitude towards its female members changed significantly between 1913 and 1918, in part because of the strong leadership skills shown by the Bodmin nurses. The National Asylum Workers’ Union Magazine no longer focused on women’s emotional temperament as a handicap to trade union membership but, instead, emphasised women’s ability for loyalty and commitment to a cause.87 Nurses’ sickness played a key role in the rise of union membership at the CLA during the First World War. The high morbidity and mortality rates among nurses contributed to the tensions between senior and junior nurses. Drawn from working-­class backgrounds, these nurses were more likely to identify with trade unionism than the professional aspirations of the College of Nursing but, I argue, it was because their work conditions deteriorated to such an extent that it badly affected health that CLA nurses wanted immediate action to force improvements. This was something the College could not offer in its early years. Comparing the impact of the war on nursing at the SDEC will explore why the College’s initial approach was more suited to voluntary hospital nursing. The South Devon and East Cornwall Hospital The health of nurses did not deteriorate at the SDEC during the First World War. Indeed, there was no increase in the number of episodes of illness compared to the preceding decade. Unlike the CLA, the 60

The First World War

main causes of sickness were tonsillitis and skin infections, similar to the late nineteenth century. No nurses contracted typhoid, a disease indicative of poor work or living conditions.88 There are a number of reasons why SDEC nurses were healthier than their CLA counterparts. Firstly, the SDEC operated and policed a strict policy preventing the admission of infectious patients, who were admitted to the two fever hospitals in Plymouth. The SDEC hospital secretary received a weekly report from the medical officer of health detailing infected houses and streets and medical staff were instructed not to admit patients, from these locations.89 Unlike the CLA, the SDEC had the capacity to isolate immediately any infectious in-­patients. Infection control was of such high priority that the hospital committee employed an architect in 1914 to improve the design and function of the isolation building. Moreover, a series of rules governed visitation rights with the specific aim of preventing outbreaks of infectious diseases in the children’s ward. Finally, the SDEC continued to teach nurses throughout the war years, including lectures on the importance of infection control. This was in contrast to the CLA where formal nurse training was not introduced until 1918. Another explanation of why SDEC nurses were healthier is that they did not experience problems of overcrowding during the war. Although the number of patient beds increased from 124 to 199 in 1914, mostly to accommodate injured soldiers, not all were occupied, with a daily average of thirty empty beds.90 In September 1914, fifty beds were allocated to the military, rising to sixty beds in October 1915. This caused consternation amongst the medical staff, who successfully complained that they were unable to admit sick civilians although beds allocated to the military remained empty. In response, military bed numbers were reduced to twenty-­five.91 Medical staff also complained that soldiers occupied beds unnecessarily, arguing that they were often fit for discharge and ‘convalescent home treatment’ shortly after admission. The problem of fit ambulant soldiers, according to the doctors, was that they took up valuable nursing time because nurses had to keep a close eye on them to prevent them escaping to the pub.92 Nurses also faced considerable demands from a number of heavily dependent civilian patients who required considerable nursing care. In 1916, the for example, the average length of patient stay was thirty-­five days compared to a national average of 61

Who cared for the carers?

twenty-­two days.93 Doctors wanted to reduce the number of long-­stay ‘chronic and incurable’ patients and increase the turnover of surgical cases and gave the shortage of nurses as reason for the change.94 Staff shortages at the SDEC were not as acute as at the CLA. SDEC nurses were called up for military service but there is no record of how many went. The numbers were high enough for management to comment that it had affected the smooth running of the hospital and, in March 1916, the chairman, Sir Henry Lopes, congratulated matron Hopkins for ‘the way she had met the difficulty caused by the serious depletion of the nursing staff’.95 In July 1916, the nursing committee applied to the Red Cross Society to supply voluntary aid detachment nurses (VADs) to help staff the wards. The VAD scheme, originated in 1909, supplied twelve thousand VADs to military hospitals and sixty thousand to auxiliary hospitals by the end of the war. Some VADs had full hospital training, others more limited nursing experience, whilst the remainder were unqualified.96 Regular nurses feared competition and were anxious that their superior status should be given formal recognition in the form of registration. Animosity between the two groups of nurses was fuelled by the BJN’s criticism of the ‘hauteur’ of the VADs.97 The promotion of nursing as a way of helping the war effort elevated the occupation’s image and temporarily influenced a change in the class background from which nurses were drawn. VADs were often from the upper and middle classes, and this was the case at the SDEC.98 Two VAD probationers had upper-­class backgrounds: Kathleen Lopes’s father was Sir Henry Lopes, chairman of the hospital and Constance Robartes’s father was the Honourable Charles Agar Robartes, owner of the 1000-­acre Lanhydrock estate in Cornwall.99 Not only were these upper-­class women unlikely to express interest in the working-­class movement of trade unionism but nor were the majority of SDEC nurses who were mostly drawn from middle-­class backgrounds in this period. Nearly half the probationers who entered training during the war paid twenty-­six guineas annually. The remainder did not pay but neither did they receive a salary, which was introduced only in September 1919, prompted by a shortage of recruits. The selection of new recruits was based on whether matron Hopkins considered them suitably ‘respectable’. The term suggested not only that the recruit 62

The First World War

came from a middle-­class background but that they understood and exemplified a set of unwritten moral values Hopkins believed necessary to elevate the status of nursing. For example, G. Gray of the Falstaff Inn, Plymouth, complained to the Western Morning News when his daughter’s application for nurse training was rejected on the grounds that she ‘was a publican’s daughter and would have to come to his house in uniform’. Hopkins explained that ‘it would not add to the dignity of the institution to have a nurse going into a public house, though it was her home’.100 Successful applicants came from professional backgrounds, like Kathleen Forster-­Morris, whose father was a vicar, and Geraldine Aldons, whose father was a senior surgeon. The probationers’ register required details of father’s occupation but this information was rarely recorded. Indeed, of the one hundred entrants between 1903 and 1918 only eighteen entries were completed and these listed predominately middle-­class occupations. Without more detailed information, it is difficult to judge nurses’ social background accurately. Certainly Hopkins, supported by the medical staff, encouraged nurses to aspire to a middle-­class lifestyle. The house committee purchased a croquet set for the nurses and encouraged them to use the hospital’s lawn tennis court by screening it to provide privacy.101 Nurses had their own sitting room, which was furnished with upholstered easy chairs, a mahogany writing table, chesterfield sofa, bookcase and piano.102 Nurses at the SDEC were forthcoming in their complaints either to Hopkins or directly to the general committee. In the late nineteenth century, The Hospital linked the rising number of nurses’ complaints to an increase in the number of middle-­class nurses entering the profession.103 The SDEC nurses made several formal complaints during the war, all of a minor nature. In November 1915, for example, night duty nurses, sleeping in the day, complained of being disturbed by soldiers playing croquet. The soldiers were immediately moved to another area of the hospital. SDEC nurses demanded a high standard of living conditions, complaints were dealt with promptly and invariably resolved in the nurses’ favour. Quick resolutions may have been prompted by a desire to retain nurses like Kathleen Lopes, the chairman’s daughter, because of the increased prestige and status these women brought to the hospital. Staff turnover increased from 1916 onwards. For the first time 63

Who cared for the carers? Table 1 The number of SDEC probationers who left training because of ill-­ health 1903–19 Year of entry 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919

No. of entrants

No. who qualified

 2

 2

 1

 1

 5  6 16 14  6  7 13  8 15  5  7 18 21

 4  5 10 11  3  7  9  6  8  3  2  7 11

Left owing to illness

Advised to leave

Died in training

2 1

3 2 1

1 (septic throat)

1 1 2 1 2 2

1 (influenza) 2 1 6 2

1 (influenza) 1 (influenza)

since the introduction of training in the 1880s, over 50 per cent of probationers left before qualifying. However, the probationers’ register may not provide an accurate picture and turnover may have been even higher than the recorded figures suggest. For example, in 1906, the house committee agreed to reimburse a Miss Dwyer £3 3s of the £4 4s she had paid for her training. Dwyer collapsed with ‘nervous prostration after five days as a paying probationer’ but her details were not entered in the probationer’s register, perhaps because her period of employment was so short.104 Table 1 shows the number of probationers who left owing to ill-­health between 1903 and 1919. During the war, numbers remained consistent at one or two per year compared to none in the three years prior to 1914. In 1917, for the first time, over fifty per cent of probationers left before qualification, and this may be explained by a change in the style of nurse management. In 1916, Harriet Hopkins retired after thirty years of service to be replaced by Alice Dickson, age thirty-­ three, who was appointed from a field of seventy-­six applicants and 64

The First World War

had trained and worked as a ward sister at the SDEC.105 She was much quicker than Hopkins to dismiss nurses as unsuitable, suggesting that she had a different set of expectations from her predecessor. There is no evidence that SDEC nurses were interested in any form of occupational representation until 1924 when Dickson insisted that new recruits became members of the College of Nursing’s Student Association at the start of training. The Association was set up to raise funds, to make the college appear less elitist and to discourage student nurses from joining trade unions. Student nurse Edna Whitell, who trained at the SDEC in the 1920s, recalled that ‘it was never thought of as a trade union’.106 Conclusion CLA nursing staff experienced much higher rates of illness during the First World War than nurses working at the SDEC. This played an important part in shaping CLA nurses’ choice of trade unionism as the most effective form of occupational representation. The college route of professionalism and its emphasis on vocation and opposition to strike action was not an option for a group of nurses whose work and living conditions had deteriorated to such an extent that their health was badly affected. The First World War had a much greater effect on staff at the CLA than those working at the SDEC. The CLA was overcrowded and lost more staff to military service, and staff suffered from restrictive food rations. As a result, the asylum was unable to control and contain infectious diseases, which posed a significant health risk to staff and patients. Its infection control policy was simply overwhelmed by the number of patients and staff requiring treatment. The SDEC, on the other hand, maintained strict control of infection throughout the war. Furthermore, SDEC staff were under less physical and mental pressure: the nurse–patient ratio was lower and, even though a significant proportion of civilian patients required considerable nursing care, a number of beds allocated to the military were always empty. Whereas the majority of CLA staff called up for military duty were replaced by untrained and inexperienced novices, SDEC staff were replaced by VADs, many of whom had previous nursing experience and were immediately enrolled on the SDEC training programme. 65

Who cared for the carers?

Unlike the SDEC, the CLA experienced problems recruiting senior nurses, who stayed for much shorter periods of time than previously. The introduction of new styles of nurse management caused tensions between senior and junior nurses in both hospitals but prompted militant strike action only at the CLA. SDEC nurses enjoyed better living conditions and were even encouraged to pursue leisure activities. CLA nurses slept, ate and washed on their wards with little importance attached to their privacy. Furthermore, the visiting committee often failed to respond to their grievances. In contrast, the SDEC management committee was keen to quickly resolve nurses’ complaints and, as a result, nurses were less militant. The minor nature of the complaints suggests that, on the whole, nursing at the SDEC during the war was more bearable than at the CLA. Evidence suggests that the notion of class was an important factor in shaping nurses’ choice of collective representation at the two institutions studied. CLA nurses empathised with the working-­class trade union movement. SDEC nurses were drawn from a mixed social background but were encouraged to aspire to a middle-­class lifestyle. Hopkins considered the notion of ‘respectability’ important when recruiting nurses and used the term to denote not only class background but also an understanding of a set of unwritten moral values that governed behaviour. It is unlikely that nurses selected on this basis and inculcated with middle-­class values would express interest in working-­class activities like trade unionism. However, SDEC nurses expressed no interest in any form of professional or industrial activity until 1924 when it became compulsory to join the College of Nursing. The fact that their health had not deteriorated during the war, and neither had their work and living conditions, meant that they had little reason to campaign for radical improvements. Female CLA nurses’ leading role in the strike challenges the assumption that women were more likely to adhere to professional values of self-­sacrifice. Indeed, the evidence suggests that women were as likely as men to reject professional ideology. The women’s decision to strike may have been influenced by the fact that female nurses suffered a higher mortality rate than their male colleagues (out of the seven staff deaths in 1917, five were female nurses).107 But both men and women suffered poor work conditions and disruption 66

The First World War

to existing patterns of nursing practice: the male side suffered staff shortages as men were called up for military duty, whilst recruitment problems on the female side meant a frequent change in the style of nurse leadership. SDEC nurses’ lack of interest in industrial action in 1918 can be read as evidence that female voluntary hospital nurses espoused professional ideology but it can also be seen as a result of their superior work conditions alongside the influence of social class. The war gave a boost to the organisation of women workers by trade unions. Female membership rose from 183,000 in 1910 to 1,086,000 by the end of 1918. Of particular interest was the growth in new membership among teachers and white-­collar workers.108 Expanding work opportunities and the relaxation of traditional expectations of behaviour, as a result of the war, had given women a new sense of confidence and freedom. Whilst it is questionable whether the war consolidated this new status women had in society, it changed the way many women thought about themselves. The threat of unionisation among general hospital nurses was used to prompt government ministers to support nurse registration. The First World War, according to an editorial comment in the BJN, ‘brought home to our employers that conditions for nurses must be improved’.109 The next chapter will explore whether the Nurses’ Registration Bill in 1919 brought concomitant improvements to work conditions. Notes 1 CRO, HC1/1/3/9, 99th Annual Report CLA 1918, p. 24. 2 National Asylum Workers’ Union (NAWU) Magazine (October – November – December 1918), 7. 3 Hart, Behind the Mask, p. 41. 4 Ibid. 5 Ibid. 6 A. J. McIvor, ‘Manual work, technology and industrial health, 1918–39’, Medical History, 31 (1987), 160–89. 7 J. C. Bridge, ‘Health’, in Annual Report of the Chief Inspector of Factories and Workshops for the Year 1932 (London: HMSO, 1933), pp. 41–57. 8 Ibid. 9 BJN (8 July 1916). 10 Bridge, ‘Health’, pp. 41–57. 11 ‘Industrial medicine in America and here’, Lancet (1919), 1199–200.

67

Who cared for the carers? 12 H. A. Waldron, ‘Occupational health during the Second World War: hope deferred or hope abandoned’, Medical History, 41 (1997), 197–212. 13 A. Hardy, Health and Medicine in Britain since 1860 (Basingstoke: Palgrave, 2001), p. 177. 14 Dingwall et al., An Introduction to the Social History of Nursing, p. 130. 15 Carpenter, Working for Health, p. 42. 16 NAWU Magazine (April 1916), 4. 17 Ibid. (21 February 1914), 168. 18 Ibid. (August 1915), 2. 19 Ibid. (April 1916), 7. 20 Ibid. 4. 21 Ibid. (May 1912). 22 Ibid. (September 1915), 10. 23 Rafferty, The Politics of Nursing Knowledge, p. 78. 24 Royal College of Nursing (hereafter RCN), RCN/2/1, The College of Nursing Ltd council minutes (1 April 1915 – 31 March 1916); 15 September 1916. 25 RCN, RCN/23/1, Articles of Association (1916). 26 RCN, RCN/2/1, The College of Nursing Ltd council minutes (1 April 1924 –31 March 1925). 27 Nursing Times (22 November 1919), 1247. 28 Nursing Mirror and Midwives Journal (8 November 1919), 107. 29 CRO, HC1/1/3/9, 96th Annual Report 1915, p. 74. 30 CRO, HC1/1/3/9, Board of Control Report (July 1915), p. 26. 31 Ibid. 32 1901 Census online, RG13, 2201. www.1901censusonline.com/results.asp? wci5person_results&searchwci5person_search. Accessed 17 February 2012. 33 1901 Census online, RG13, 2201. www.1901censusonline.com/results.asp? wci5person_results&searchwci5person_search. Accessed 17 February 2012. 34 CRO, HC1/1/1/16, CLAVC minutes, 25 January 1915. 35 CRO, HC1/1/3/9, 96th Annual Report 1915. 36 CRO, HC1/1/3/9, Board of Control Report, July 1916. 37 CRO, HC1/1/1/16, CLAVC minutes, 31 May 1915. 38 CRO, HC1/1/1/18, CLAVC minutes, 25 November 1918, p. 316. 39 CRO, HC1/1/1/15, CLAVC minutes, 27 July; 28 September; 26 October 1914; 26 February 1915. 40 CRO, HC1/1/1/15, CLAVC minutes, 26 February 1914, p. 394. 41 CRO, HC1/1/1/16, CLAVC minutes, 29 March 1915, p. 100. 42 CRO, HC1/1/3/9, 95th Annual Report 1914. 43 CRO, HC1/1/1/16, CLAVC minutes, 29 March 1915, p. 101. 44 CRO, HC1/1/1/16, CLAVC minutes.

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The First World War 45 CRO, HC1/1/3/9, 96th Annual Report 1915. 46 CRO, HC1/1/1/16, CLAVC minutes, 22 February 1916, p. 47; HC1/1/3/9, 96th Annual Report 1915. 47 H. Pennington, ‘Don’t pick your nose’, London Review of Books, 27:24 (13 December 2005), 29–31. 48 CRO, HC1/1/3/9. Board of Control Report, April 1918, p. 27. 49 CRO, HC1/1/3/9, 100th Annual Report 1919, p. 8. 50 Andrews, The Dark Awakening, p. 221. 51 CRO, HC1/1/3/9, Board of Control Report, April 1918, p. 27. 52 CRO, HC1/1/3/9, 98th Annual Report 1917, p. 7. 53 CRO, HC1/1/1/18, CLAVC minutes, 29 July 1918, p. 240. 54 Ibid., 28 October 1918. 55 Ibid., 29 October 1917, p. 42; 29 July 1918, p. 232. 56 CRO, HC1/1/3/9, 98th Annual Report 1917, p. 8; HC1/1/1/18, CLAVC minutes, 27 January 1919, p. 359. 57 NAWU Magazine (October – November – December 1918), 6. 58 CRO, HC1/1/1/18, CLAVC minutes, 29 October 1917, p. 42. 59 Ibid., 26 August 1918, p. 254. 60 NAWU Magazine (October – November – December 1918), 6. 61 CRO, HC1/1/3/9, 99th Annual Report 1918, p. 24. 62 CRO, HC1/1/1/18, CLAVC minutes, 29 July 1918, p. 232. 63 Carpenter, Working for Health, p. 71. 64 F. R. Adams, ‘From association to union: professional organisation of asylum attendants’, The British Journal of Sociology, 20:1 (March 1969), 19. 65 NAWU Magazine (October – November – December 1918), 6. 66 Bodmin Guardian (29 October 1918). 67 Ibid. 68 NAWU Magazine (October – November – December 1918), 8. 69 Ibid., 7. 70 CRO, HC1/1/1/18, CLAVC minutes, 26 October 1918, p. 276. 71 Ibid., 27 November 1918. 72 CRO, HC1/1/3/9, 99th Annual Report 1918. 73 CRO, HC1/1/1/18, CLAVC minutes, 4 November 1918, p.  295; 18 November 1918, p. 299. 74 Ibid., 27 January 1919, p. 359. 75 Ibid., 30 December 1918, p. 335. 76 CRO, HC1/1/1/19, CLAVC minutes, 24 February 1919. 77 Ibid., 1 July 1919. 78 Ibid., 26 April 1919. 79 CRO, HC1/1/3/9, 99th Annual Report 1918. 80 CRO, HC1/1/1/18, CLAVC minutes, 25 November 1918, p. 312. 81 CRO, HC1/1/3/9, Board of Control Report 1919. 82 Carpenter, Working for Health, p. 75.

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Who cared for the carers? 83 Ibid., p. 77. 84 NAWU Magazine (January – February – March 1919). p. 17. 85 Ibid. p. 16. 86 Ibid. (April – May – June 1919), p. 13. 87 Ibid. (October – November – December 1918), p. 6. 88 PWDRO, 1490/24, SDEC Register of Nurses, 1903–23. 89 PWDRO, 606/1/11, SDEC general committee minutes, 10, 22, 23 July 1914. 90 Ibid., 15 March 1916, p. 192. 91 Ibid., 4 May 1916. 92 Ibid., 17 February 1915. 93 Ibid., 15 March 1916, p. 199. 94 Ibid., 15 March, 27 October 1916. 95 Ibid. 96 Abel-­Smith, A History of the Nursing Profession, p. 86. 97 Rafferty, The Politics of Nursing Knowledge, pp. 77–8. 98 Summers, Angels and Citizens, p. 278. 99 PWDRO, 1490/24 SDEC Register of Nurses, 1903–23. 100 ‘Licensee’s Protest’, Western Morning News (11 July 1913). 101 PWDRO, 606/1/18, SDEC Hospital house committee minutes, 29 July 1904. 102 Ibid., 28 May 1907. 103 The Hospital (19 July 1890), 240. 104 PWDRO, 606/1/22, SDEC Hospital house committee minutes, 13 November 1916. 105 Ibid., 30 June 1916. 106 H. M. Goodman, The History of Greenbank Hospital (Plymouth, 1978), p. 90. 107 CRO, HC1/1/3/9, 99th Annual Report 1918, p. 24. 108 Dingwall et al., An Introduction to the Social History of Nursing, p. 86. 109 BJN (1 March 1919), 135.

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3

The Nurses’ Registration Act, 1919

In 1919, the newly appointed Minister of Health, Dr Christopher Addison, acknowledged that nurses’ ‘conditions of employment were one of the most essential needs of the time’. He admitted that ‘they had been scandalously underpaid and often grossly overworked’.1 Yet Addison refused to allow the discussion of work conditions on to registration’s agenda and prevented nurse organisations seeking linked economic benefits as part of the Registration Bill. While the subject of nurse registration has attracted considerable historical attention, its impact on attitudes towards the health of nurses has been neglected. At the time, nurse leaders predicted that they would be able to stipulate conditions of service once professional status had been achieved. They reasoned that if nurses were better educated and more highly trained then improvements to economic conditions would follow. Yet their prediction failed to materialise and, although asylum nurses achieved standardised work conditions by 1919, voluntary hospital nurses’ work remained unregulated despite the award of professional status. The timing of the government’s Registration Bill has traditionally been explained by the impact of the First World War. An influx of voluntary aid detachment nurses (VADs), Anne Summers argues, complicated the issue of who was qualified to nurse, and the College of Nursing wanted to control the nurse labour market by stipulating conditions of entry and training.2 The award of professional status is interpreted as chiming with public and political sympathy towards improving the status of women through female suffrage.3 However, the more likely historical explanation is that registration fitted in with government’s plans for postwar social reconstruction.4 This chapter 71

Who cared for the carers?

focuses on the politics of voluntary hospital nursing rather than registration’s impact on nursing at the case study hospitals. It argues that only by understanding the motives that shaped nurse organisations’ response to government strategies in 1919 can we explain why nurses’ health failed to attract policy makers’ attention until the mid-­twentieth century. Before analysing the politics of the bill, an overview of the impact of the First World War on women’s position in society will set the issue of registration within the wider context of women’s work. The impact of the First World War on women’s work The influence of the war on women’s work is contentious.5 On the one hand, little changed as women were expected to conform to prewar values. Although the war pushed women into jobs traditionally defined as male, the backlash against women workers in industry meant that many women returned to domesticity in 1919. Despite the fact that women over the age of thirty won the vote in 1918, few women were elected to Parliament.6 The number of women in work in 1921 was similar to that in 1911, but the types of opportunities open to them were changing. For example, those employed in domestic service dropped from 1.65 million in 1914 to 1.25 million in 1918.7 These shifting patterns had important implications for nursing because of the competition it faced from a range of occupations offering respectable work with better work conditions. Teaching offered decent prospects with shorter hours, long holidays and a good salary of around £150, equivalent to a matron’s salary. As standards of education rose, career opportunities in white-­collar occupations expanded. In the late nineteenth century, offices were male enclaves but, with the introduction of the typewriter, clerical work was transformed into a woman’s job. Although, in its early years of expansion, many commentators thought typewriting offices had all the characteristics of a sweated industry, conditions were better than in many other forms of work. The majority of typists worked from 9 a.m. until 6 p.m. with an hour for lunch, and salaries ranged from £22 to £150.8 Trained nurses’ salaries ranged from £30 to £60 but included board and lodging.9 Typists’ hours compared favourably with voluntary hospital nurses who, in 1919, worked from fifty-­two to eighty-­six 72

The Nurses’ Registration Act

hours per week on day duty and fifty-­nine to eighty-­four hours on night duty. Nurses’ complaints about poor pay, long working hours, ‘continual worry’ and ‘physical overstrain’ featured in a plethora of articles and correspondence columns in the nursing press in 1919, written to encourage nurse organisations to pursue the issue of work conditions as part of registration’s agenda.10 The creation of the Ministry of Health and its attitude to nurse registration The Ministry of Health was created following years of debate on the responsibilities of the state towards the nation’s health. With wide-­ ranging responsibilities, the Ministry has been seen historically ‘as uneasily balancing central, local and private interests, including poor law authorities and the private insurance companies that managed most of the nation’s health insurance since 1911’.11 The duties of the Local Government Board, the National Insurance Commission, the powers of the Board of Education in relation to health and the responsibility for the Midwives Act were transferred to the Ministry of Health.12 Dr Christopher Addison, a medical doctor and liberal politician, who served as Minister of Munitions during the war, was appointed Minister of Health.13 Whilst its supporters hoped that it would be a move towards a more integrated health service, its critics managed to limit the Ministry’s agenda.14 The Ministry had two roles in the government’s postwar reconstruction plans: firstly, to inspire soldiers in the promise of a ‘land fit for heroes’ and, secondly, to contain social unrest caused by the disruptive effects of war on the national economy. From its inception in 1919, the Ministry of Health realised the advantages that could be gained from having a register of trained nurses at their disposal. It would enable the identification of trained and efficient nurses who could then be helped to move to where they were needed.15 Addison considered nurse registration to be ‘an essential element in any real improvement of existing medical services, particularly for the industrial population’.16 Realising the potential of a co-­operative relationship with nursing, Addison sought to use the issue of registration to his advantage.17 Addison did not intend to improve nurses’ work conditions as 73

Who cared for the carers?

part of the Registration Bill and offered professional status on the condition that nurse organisations did not seek to extract linked economic benefits. Addison met the three participating organisations (College of Nursing Ltd, the Association of Hospital Matrons18 and the Central Committee for the State Registration of Nurses)19 separately, on the premise that the years of bitter rivalry and disagreement between nurse leaders during the campaign for registration had made it impossible for him to achieve any form of agreement in a limited time scale if he allowed joint discussion. This strategy effectively undermined the political strength nurse organisations might have gained from acting together. From the outset, Addison intended to prevent nursing becoming a powerful, autonomous profession. By 1919, factions had developed within registration’s supporters. When the private members’ procedure for legislation resumed at the end of the First World War, the College of Nursing and the Central Committee for the State Registration of Nurses presented separate registration bills to Parliament. These bills aroused sufficient opposition to prevent any real progress. Disagreement focused on what was implied by registration and was exacerbated by personal and sectional issues that could not be reconciled.20 The College proposed a system of voluntary accreditation ensuring a basic uniformity of curriculum and assessment between the various training schools but leaving voluntary hospitals with considerable influence over the standards required. The Central Committee, led by Gordon Fenwick, advocated a set of occupationally determined standards, regardless of their practical implications.21 Tension between the two organisations ran high. The Central Committee criticised the College’s bill for serving the interests of employers and presented itself as the representative of the ‘rank and file nurse’. Yet it was made up of organisations like the Royal British Nurses’ Association, who were socially exclusive and barred poor law and asylum-­trained nurses from their membership.22 The nursing press, and national newspapers, took sides in the debate: an editorial in The Times, for example, argued that ‘nurses are too much at the mercy of their employers and they lack effective means of making their difficulties and grievances known’.23 Addison stated that he was unable to prevent the spectacle of two professional organisations ‘airing their private feuds before the forum of public opinion’ and abandoned attempts to bring them together.24 74

The Nurses’ Registration Act

The government introduced its own Bill of Registration in October 1919, exploiting nurse organisations’ history of disagreement to ensure that demands concerning work conditions were squashed. The division between the College and the Central Committee played into the hands of the Ministry of Health, which was able to impose its own agenda of change on to a split profession. Sir Robert Morant, Permanent Secretary to the Ministry of Health, explained to the Association of Hospital Matrons: the failure of the two private Bills had made it clear that there was no chance of any private Bill being carried … The pressure of parliamentary time was very great, and there was no chance of a Government Bill being passed unless substantial agreement could be secured. This meant, therefore, that both sections must be content with something less than they had hitherto hoped for.25

Reform was ‘ten years overdue’, according to Addison, but he proposed to confine it within the smallest possible compass … that it would merely set up a suitably composed Registration Council, on whom could be conferred by the Bill the responsibility for working out suitable regulations, subject to the approval of the Ministry of Health.26

Nurse organisations would ‘not deal with such questions as conditions of service and hours of labour’. Instead it was to be the policy of the Ministry of Health itself ‘to safeguard in the course of administration the conditions of service of nurses’.27 Although the Ministry did not specify how it would achieve these ‘safeguards’, Rafferty argues that ‘plans for rationalising the health services may well have been what officials had in mind’.28 Addison’s tactics paid off and all three organisations complied with his instructions not to lobby for improvement to nurses’ work conditions. Gordon Fenwick and her supporters had hoped that legislation would empower the General Nursing Council to exert some control over conditions of service and eliminate ‘sweated labour’ from nursing.29 However, Addison’s insistence that he was ‘not prepared to take the responsibility of introducing the bill on any other terms’ than his own or to discuss the ‘highly technical details of nursing works, and training … in the unsuitable arena of the House of Commons’ put an end to such expectations.30 Addison’s 75

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reluctance to address nurses’ poor work conditions may be explained by the government’s intention to include nurses in legislation aimed at improving all workers’ conditions whether in factories, shops or hospitals. The Hours of Employment Bill, 1920 In 1919–20, two contentious government measures, on hours of employment and national insurance, demanded a response from nurse organisations.31 Promoters of the Hours of Employment Bill, introduced in 1920, argued that in terms of postwar reconstruction, it would not only benefit workers by enforcing a forty-­eight-­hour week but also improve productivity and the economy.32 The wartime effort to improve production in munitions and other heavy industries had meant a relaxation in prewar legislation. Some factory workers were on duty for up to 108 hours a week and shifts of twenty-­nine hours were documented. Wartime experience put nurses under pressure to work whatever hours were necessary to deal with emergencies.33 Although the end of war reduced the need for high productivity in munitions, the experience altered workers’ expectations.34 Conditions of work gained a much higher profile, supported by the increasing strength of the unions and the Labour Party. The government was unsure how to class nurses and so debated whether nurses should be included in the Hours of Employment Bill. Sir David Shackleton, Permanent Secretary at the Ministry of Labour, thought ‘nurses would probably be classed with domestic workers and therefore not included’.35 Grouping nurses with unskilled domestic workers was a contentious comparison because of nurse leaders’ struggle since the late nineteenth century to establish boundaries between ‘old’ domestic-­style nurses and ‘new’ professional nurses. Clearly the government had not correlated registration with professional status and nurse leaders’ hopes that registration would bury connections with domesticity began to fade. In 1919, Rachel Cox Davies, matron of the Royal Free Hospital and member of the College of Nursing Council, summarised the College’s position: Trained nurses had now been given legal status, they had a defined position, and as professional workers they ought not to be brought under an Industrial Act … The only way in which they could be brought under it was

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The Nurses’ Registration Act as domestic workers and they should not be placed in that category because domestic work was not recognised as skilled professional work as nursing was.36

Shackleton invited nurse organisations to the Ministry of Labour to discuss the proposed legislation, but his initial optimism that a consensus would be easily attainable diminished when disagreement prevailed as to what form regulation should take.37 The conflict that had characterised the campaign for registration returned. The problem was that the College, the Central Committee for the State Registration of Nurses, the General Nursing Council and nurses’ trade unions held different ideas about how restricting working hours would affect nurses and their work. Gordon Fenwick, and the Central Committee, argued that a reduction in working hours would improve the mental health of nurses. The dominant view in this period was that the nurse, rather than her employer, was responsible for maintaining optimum mental health. Matron M. Vivian of Princess Christian’s Hospital, Weymouth, summed up this philosophy, suggesting that it was the nurse’s duty to view life through ‘rose-­colored spectacles. A gloomy view of life, pessimistic forebodings and an unhealthy conception of her responsibilities is a very poor outlook.’ Vivian bluntly advised those who could not find happiness from their work ‘to give it up’.38 Gordon Fenwick, on the other hand, considered employers responsible for ensuring that nurses’ work conditions were conducive to mental health. Nurses were suffering from a lack of ‘spirituality’, according to Gordon Fenwick. This was a novel idea and ahead of its time: the notion that spirituality was integral to a person’s mental wellbeing did not attract psychiatrists’ interest until the late twentieth century.39 Gordon Fenwick used the term in a wider sense than referring simply to religious activity. Her understanding meant participating in any purposeful intellectual activity that was beneficial to mental health: ‘religion, literature, the sciences, everything, in fact, which has to do with the intellect’.40 Care of nurses’ ‘spirituality’, Gordon Fenwick argued, had been neglected: largely because the profession has never taken care of itself, the spiritual life of the nurses has been made subservient to the economic convenience of the community at large … many who entered the profession … have become soured, sad, soul-­less, broken things.41

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She considered that shorter hours and greater leisure would ‘awaken the understanding to the treasures of mind and spirit’.42 Gordon Fenwick’s concern about nurses’ mental health had developed during her time as editor of the BJN. For example, in 1912, she published a paper by German physician Dr Geheimerat Hecker that described the relationship between cultural change, work conditions and nurses’ physical and mental health. Hecker’s paper is important for two reasons: firstly, because it was one of the first to attempt a physiological analysis of the causes of nurses’ fatigue and for that reason it is worth discussing in some detail. And, secondly, Gordon Fenwick reprinted it in 1919 in the BJN to raise nurses’ awareness of ­occupational health issues during the registration debate. As Chapter 1 showed, nurses had complained of ‘overtiredness’ as a result of long working hours since the late nineteenth century.43 In 1911, this broad understanding was given the more specific title of ‘overstrain’ by Hecker. Hecker developed his study of ‘fatigue and of the toxins and anti-­toxins of fatigue’ among nurses in Germany and Austria from studies on schoolchildren and industrial workers in Turin, Italy.44 His paper was introduced to the International Congress of Nurses in 1912 as the first to deal ‘with the overstrain of nurses from a scientific standpoint’. Long working hours and poor work conditions, Hecker argued, caused a type of fatigue in nurses that produced specific physiological changes, symptoms and results. Hecker maintained that, whereas fatigue lowered the limit of irritability of neurones, which, after a period of recuperation, returned to normal, overfatigue meant that neurones took longer to return to normal and, in order to compensate, the body produced toxic substances which consumed bodily tissues. Hecker identified the symptoms of ‘overfatigue’ as rapid pulse, shortness of breath, rise in temperature and ‘decreased working power’, and argued that, if untreated, they caused acute inflammation of muscles, neuralgia, cramp, nervous palpitation, diabetes and enlargement of the heart and liver.45 Mental ‘strain’, he argued, was often the result of ‘overstrain’. Mental strain among German nurses was caused by a combination of poor work conditions and the increased pace of modern life, according to Hecker. The notion that the pace of life was the root cause of illness and disease became popular in the late nineteenth and 78

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early twentieth centuries.46 There was a fear that the nervous system was ill adapted to cope with the complexity of modern life. George Beard (1839–83), a noted American physician, described the state of ‘neurasthenia’ as nervous exhaustion characterised by symptoms such as fatigue and morbid anxiety and caused by the inability of the nervous system to meet the demands of daily life.47 Hecker claimed that the strain of nursing was exacerbated by the intensive nature of the work, dealing with seriously ill patients, and inexperienced ­probationers being placed on night duty on their own.48 It is difficult to gauge whether Hecker’s research had any real influence in Britain. Certainly it prompted discussions about the theme of ‘overstrain’ within the pages of the BJN. For example, Margaret Breary, treasurer of the International Council of Nurses and assistant editor of the BJN, discussed its causes among British nurses, in a paper she presented to the International Congress of Nurses (an organisation founded by Gordon Fenwick) in Cologne in 1912, which was subsequently published in the BJN. Breary argued that the phenomenon of ‘overstrain’ in British nurses was caused not only by poor work conditions but also by nurses’ lack of knowledge: Nothing is a more fruitful source of overstrain than lack of knowledge. Knowledge gives confidence and a sense of power to deal with difficult situations which is otherwise unattainable … hence the responsibility resting upon hospital authorities to provide adequate instruction and experience to their pupils.49

Breary berated employers to take more responsibility for nurses’ health by providing ‘good food and sufficient time for rest and recreation’. Apart from Breary’s paper, there was little reference to Hecker’s research until September 1919, when the BJN republished his original paper to coincide with the government’s Registration Bill. Prevented from formally raising the issue of work conditions, Gordon Fenwick reported scientific research on health issues to raise nurses’ awareness in the hope that they would lobby for improvements to work conditions. There is no evidence that the College of Nursing was influenced by Hecker’s notion of ‘overstrain’ or the idea that a reduction in working hours would benefit nurses’ health. While the College aimed for better conditions for nurses, it wanted to uphold the notion of professional status and not respond like a trade union. The question 79

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of working hours compromised its position. It sought self-­regulation on the grounds that nurses’ needs were unique and incomparable with other groups of workers whilst realising that action was necessary to prevent nurses being exploited. Although the College’s report on nurses’ salaries and conditions of employment had supported a forty-­eight-­hour week in April 1919, it argued against a reduction in nurses’ hours in 1920, on the grounds that working hours were a professional matter that would not benefit from state intervention. It resented state interference and the implications this would have on its standing as a self-­regulating, autonomous organisation. When asked to respond to the Hours of Employment Bill, the College insisted that nurses be included in a ‘special order’ Bill that allowed the Minister of Labour to consider nursing as a unique occupation and set hours accordingly. Under this special order, the College recommended a fifty-­six-­hour week, supported by the majority of its members. The College was determined that hospital management and matrons retain as much control of work conditions as possible. It opposed the Ministry of Labour’s proposal that overtime be paid as extra wages, arguing that matrons should hold the right to compensate overtime with extra time off duty at the hospital’s convenience, thus ­reinforcing the matron’s authority over the nurse.50 Many College members continued to associate long working hours with dedication to duty.51 The subject received extensive coverage in the nursing press, where members campaigned against regulation by questioning how working hours could be prescribed for an occupation ‘founded upon a spirit of service to the community’.52 Members reshaped the analogy of motherhood used by Eva Luckes’s late nineteenth-­century campaign against nurse registration. This time, in the age of imperialism, members compared nurses to the ­quintessential self-­sacrificing role model of English mothers: Does any service with aims like ours measure its labour by time? Is sacrifice to be denied us? What of the English mother in an average English home? Her hours are countless yet the public seems to regard such as right and proper. Are we not doing woman’s work too?53

One of the consequences of linking maternal qualities with the image of the nurse was to obscure the perception of nursing as a health hazard. Just as mothers cannot go off duty or report in sick because of 80

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a cold, so nurses were expected to show the same level of self-­sacrifice even when work conditions threatened their health. Critics of the Hours of Employment Bill also argued that a reduction in hours would have a detrimental effect on the nurse–patient relationship and the nurse’s ability to provide continuity of care. The idea that nurses should care for their patients day and night had become part of the ‘new’ nurse’s image during the registration campaign. One commentator, writing in the Nursing Mirror, used this idea to lobby against the introduction of eight-­hour shifts: The patient seems to have been quite lost sight of, and the eight-­hour shift would be greatly to his disadvantage. It would be impossible to keep pace with changes in his condition.54

Criticism that the College of Nursing had failed to address poor work conditions in the debate on nurse registration led to the formation of the Professional Union of Trained Nurses (PUTN) in November 1919. The PUTN had a very small membership of 268 nurses compared to the 17,336 members of the College.55 But, despite its small membership, it received considerable press coverage, particularly from the BJN, whose aim was to undermine the College by highlighting nurses’ grievances. The PUTN supported the Hours of Employment Bill and accused the College of prioritising hospitals’ economic interests. Many voluntary hospitals were in dire financial straits and a forty-­eight-­hour week would force them to employ extra nurses. The PUTN leader was Maude MacCullum, a private nurse and prominent member of one of the strongest and most successful nursing co-­operatives in London. She was also a founding member of the first provisional nursing council and loyal supporter of Gordon Fenwick.56 MacCullum challenged the notion that health risks must be endured to demonstrate commitment to duty: ‘vocation’ meant ‘serfdom’, according to MacCullum, and was the cause of ‘premature disability and dependence.’57 MacCullum wanted the health risks of nursing acknowledged and conditions improved to reduce levels of nurses’ sickness. O’Dwyer, another private nurse, and speaker at one of the first PUTN meetings, argued that the ‘hospital system which worked to relieve one class of invalids was creating another … Invalidity was caused by the long hours, such as no class of labourer 81

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would tolerate, the hurried meals and the strain of the care of so many acutely sick people.’58 Eight of the PUTN’s nineteen objectives were aimed at improving the health and welfare of nurses but its failure to attract members suggests that the majority of nurses did not consider these issues important. The Hours of Employment Bill was eventually dropped, to be revived again, unsuccessfully, in 1924. The Unemployment Act of 1920 The second piece of government legislation was intended to bring most groups of workers, including nurses, into the remit of compulsory unemployment insurance. Unemployment had fallen during the war as men were conscripted and large numbers of women had taken their work places. As war ended, a workforce used to official direction compounded difficulties finding employment for homecoming troops. A brief postwar boom was followed by rising unemployment. Growing industrial unrest and a fear that unemployment would contribute to the rise of ‘bolshevism’ may have prompted the government to introduce the Unemployment Act of 1920. Agricultural and domestic workers were exempt as it was thought there was little unemployment in these groups. Nurse organisations, unusually united in agreement that legislation would undermine their professional status, decided to vote against the Bill. The Ministry of Labour held a joint enquiry attended by representatives from the College of Nursing Ltd, Royal British Nurses’ Association, National Union of Trained Nurses, British Hospitals Association and Queen Victoria Jubilee Institute. Again, the question of nursing’s inclusion turned on its association with domestic work. Gordon Fenwick, representing the Royal British Nurses Association, asked whether unemployed nurses were ‘to tramp daily in queues to the Employment Exchanges with “chars” and other out-­of-­work women for a weekly wage of 12s? It is scandalous that the law provides that they should do so.’59 On the one hand, her response conveys a sense of superiority that nurses were a class above other groups of women workers but on the other, it also illustrates nurse leaders’ determination to raise professional status by creating social boundaries. Nurse organisations set out to convince the Minister of Labour 82

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that ‘there was little unemployment amongst hospital nurses’.60 Although charities, including private convalescent and holiday funds, often claimed it was common for nurses to be unemployed owing to ill-­health, there was little statistical evidence to substantiate these claims. In 1922, 701 nurses out of nursing population of 122,804 were registered as unemployed although it is not known whether these were trained nurses.61 Old age accounted for the majority of unemployment, according to E. Nicholls, secretary of the National Union of Trained Nurses, pointing out that few matrons would accept a nurse over forty.62 The physical hardship of nursing was considered unsuitable for older women on the grounds that they had ‘usually lost adaptability and the powers of readily receiving new impressions’. In 1920, when the average female life expectancy was approximately fifty-­five, this attitude towards older nurses is understandable.63 Sick nurses were already insured under the National Insurance Act but, according to the RBNA, did not always apply for benefit ‘because they found the panel system irksome’.64 Under the 1911 Act, all eligible employees were placed on a ‘panel’ of a named general practitioner who received an annual capitation fee to provide for their general medical care. But the panel system had evolved into a two-­tier system of health care with panel patients frequently queuing at the back door to enter cramped surgeries whilst paying patients chose personally convenient times for appointments, were greeted by a maid and waited in a comfortable room for an extended appointment with the doctor.65 Some nurses complained about being panel patients; they resented disclosing personal information to insurance companies and preferred London specialists to provincial panel doctors. Class assumptions, according to Anne Digby, shaped c­ onversations about whether working-­class panel patients were second-­class citizens compared to middle-­class paying patients.66 Indeed, the notion of class helps explain the RBNA’s comment above: middle-­class nurses may have objected to participating in a scheme they considered suitable only for the working classes. To convince the Ministry of Labour not to include nurses in the Unemployment Bill, the College of Nursing organised a referendum of its members. Nurses were asked only one question, framed to support its point of view: ‘Do you wish the College to use every effort to get, if it is possible, nurses excluded from this Act?’67 The 83

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College lobbied hospital matrons to rally ‘a sufficiently strong protest’ against the legislation and instructed branches to collect only the signatures of those nurses ‘who wish to be exempt … under this Act’.68 Cox Davies, representing the college, reported to the Minister of Labour that 80 per cent of the three thousand nurses questioned were opposed to inclusion.69 The College also encouraged nurses to lobby their MPs and the Minister of Labour to support an amendment making a special case for nurses. The amendment was successful and the new Act, legislated in April 1922, excluded nurses. Charity for sick nurses The use of charity money to aid sick nurses was seen by some commentators as an indication of the College’s failure to address nurses’ economic problems. In 1920, the editor of the Daily Telegraph started a Shilling Fund aimed at raising money from military personnel for sick nurses. Stories of individual nurses were told to encourage donation. ‘Were the heartrending cases of misery and want amongst some of our nurses more widely known’, the editor argued, ‘there are thousands of people who would give their shillings’.70 A nurse complained, at a Labour Party meeting in 1920, that the Daily Telegraph’s ‘charity appeal was a poor substitute for justice and was a menace to the economic position of nurses’.71 Questions were raised about whether the College benefited financially from perpetuating an image of the nurse as an object of charity. The College was partly funded by the Nation’s Fund for Nurses, a charity set up by the British Women’s Hospital Committee in 1918 under the War Charities Act. The Nation’s Fund was to be divided into two parts: a tribute fund to benefit all nurses and an endowment fund for the College of Nursing. The College’s chairman, Sir Arthur Stanley, was a member of the Fund’s management committee and had complete discretion over the endowment fund.72 Problems arose for the College when it encouraged the public to donate to the Nation’s Fund by declaring that nurses ‘were poor, over-­worked, underpaid creatures who [could] barely support themselves and had no means of making provision for their old age’.73 The PUTN obtained extracts from the Nation’s Fund balance sheets, which appeared to show that the College had received £80,635 16s 4d in donations from the Fund 84

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during 1919–22. Stanley denied that such money existed.74 Doubts were expressed about the College’s motivation to improve nurses’ salaries following allegations that it profited from promoting a pitiable image of the nurse. ‘A huge charity fund’, according to Gordon Fenwick, ‘tends to lower the standard of pay and to encourage an inevitably dependent spirit’.75 In its defence, the College argued that it was ‘working hard to obtain fair pay for nurses but in the meantime it [had] done magnificent in helping many old or sick nurses who would otherwise have drifted to the poor law infirmary or even the workhouse for maintenance’.76 In 1919, the College recommended that a superannuation fund be set up through the Royal National Pension Fund. Sir Cooper Perry, one of the College’s three founding members, was also a member of the Fund’s council. Despite the Fund’s financial success (it had invested funds of £2,160,912 in 1921) only 2,891 nurses received annuities. Although membership had increased in 1920, few nurses could afford to continue paying their premiums. As a result, over three thousand nurses cashed in their policies between 1918 and 1921. In 1921, the Fund admitted that a pension ‘average only 10s per week’ was only a ‘small addition to an official pension’ and that for many nurses there was no alternative to ‘accept weekly doles or end their days in the workhouse’.77 The College of Nursing versus the National Council of Women Nurses’ poor work conditions attracted the attention of the National Council of Women (NCW) in 1919. Interest from a non-­nursing organisation not only raised public awareness of the plight of nurses but also focused attention on the role of the College of Nursing. The National Union of Women Workers (NUWW) was formed in 1895, changing its title to the National Council of Women (NCW) in October 1918. Led by middle-­class women, the NCW took up issues that could be considered their natural domain, claiming them as areas of women’s expertise. Recent studies suggest that women did not enter national politics in large numbers once women over thirty obtained the franchise in 1918, though they were politically active in other ways.78 Some women believed that obtaining the vote was only part of the process to equality in citizenship. During the first quarter 85

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of the twentieth century, a number of groups formed or reshaped, including the National Federation of Women’s Institutes, the Young Women’s Christian Association and the Mothers’ Union, with the aim to educate and further women’s issues. Such groups became an accepted form of political involvement for women who did not want to engage in the radical feminist politics of the prewar years. The NCW reflected this broad approach to politics and was active on a wide range of concerns: for example, in 1918, its council meeting discussed a diverse range of subjects including hostels for mothers and babies, equal pay and laws of naturalisation.79 Several nurse organisations established close links with the NCW and routinely sent representatives to its meetings and conferences. The College of Nursing was often invited to respond to NCW resolutions and commented on a range of subjects including women police patrols and infant protection.80 In 1918, such were the close political ties between the two organisations that the College shared its ‘aims and objects’ with the NUWW.81 The issue of nurses’ occupational health, however, was to prove divisive. In February 1919, the NCW invited the College of Nursing, as well as the RBNA, the Poor Law Matrons’ Association and the BMA to a preliminary conference with the intention of forming a joint committee to enquire into nurses’ work conditions.82 The initiative for this conference came from Dr Herbert Crouch, a supporter of the National Union of Trained Nurses and medical adviser to the Nurses’ Co-­ operative. Crouch argued that he had seen many nurses suffering from chronic complaints, which he linked to the hardships they experienced as probationers. He was determined to set up an investigation and offered the NCW £500 to cover their committee’s costs.83 Although the College had already decided to set up its own committee to investigate nurses’ pay, it agreed to work with the NCW ‘in order to avoid overlapping’. ‘It [seemed] a waste of effort’, according to Marie Matilda Ogilvie Gordon, president of the NCW, ‘for two committees to be working independently’.84 The College appreciated the limited political weight its own findings would carry in comparison to the NCW’s: any recommendation for the economic betterment of nurses would have greater weight with the public, and even with the nurses themselves, if coming from a Committee composed largely of persons who are recognised authorities on women’s work and welfare.85

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Criticism in the national and nursing press that the College p ­ rioritised hospitals’ finances undermined its authority. Within weeks of deciding to work together, and much to the annoyance of Ogilvie Gordon, the College returned to its original plan to hold its own independent inquiry. The ‘salaries committee had already made such progress with its enquiries’, the College argued, ‘and so enlarged its personnel that any suggestion of merging its work, and membership in your Special Committee has become more than ever impracticable.’86 Gordon complained that ‘this overlapping is to be regretted since the NCW is, as a neutral body to which the various nursing associations are affiliated, in a unique position to conduct such an inquiry’.87 Disagreement about the composition of the joint committee prompted the split. The College insisted that only women whose names carried political weight be included, with a small number of nurses, while the NCW proposed that the committee should comprise two representatives from each nursing organisation. One possible reason for the College’s cool attitude is that it wanted to distance itself from NCW politics. McGann et al. note that, whilst the NCW was not an overtly political group, its ten-­person committee consisted of former suffragists, including Elizabeth Haldane and Rosa Barrett.88 Whether the College feared it would pursue a feminist agenda is difficult to know. Certainly, the NCW had proven expertise as a campaigner to improve women’s occupational health. For example, in 1913, its concern for women factory workers led to a campaign to lobby government departments about the ‘totally inadequate number of women factory inspectors’.89 Its aims suggest a feminist agenda, ‘to promote the civil, moral and religious welfare of women, to focus and redistribute information likely to be of service to women workers’ but, in 1918, it was slowly moving towards a more egalitarian position by eliminating the word ‘women’ from its constitution to enable societies governed by men with women members to be eligible for affiliation.90 Another possible explanation for the College’s reluctance to participate in a joint enquiry could be that it feared a survey would reveal an extensive occupational health problem, thus forcing it to take more responsibility to improve work conditions. The College was keen to retain the support of hospital managements and was wary of increasing their financial burden, particularly during the process of 87

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nurse registration. Whether the NCW deliberately timed its enquiry to coincide with the gathering pace of nurse registration is unclear but it put the College in a difficult position. Both organisations simultaneously sent separate questionnaires to hospitals enquiring into nurses’ work conditions. This was the first time that national organisations had investigated the salaries, hours and accommodation of nurses on such a wide scale but, according to the BJN, the opportunity ‘to prove the necessity for a thorough inquiry’ was lost.91 The impact that one large joint enquiry might have made was limited by information being disseminated across two reports. The rivalry and quarrelling that had characterised the campaign for nurse registration continued, although in this case a non-­nursing organisation was involved. Gordon Fenwick led the opposition to the College; she joined the NCW’s committee and used her position as editor of the BJN to further its aims. She blamed the nursing press affiliated to the College for starting a campaign ‘urging matrons not to answer the NCW questionnaire both on account of its “inquisitorial” character and because the College of Nursing had already sent out their questionnaire’.92 The College emerged the victor in so far as it received more replies to its questionnaires. It sent out two types of questionnaire: type one was sent to general hospitals, poor law institutions, epileptic colonies and dispensaries and type two to nursing institutions, convalescent homes, medical officers of health, workplaces and consumptive sanatoria.93 It received 514 replies to the 1,297 type one questionnaire sent out and 240 replies to the 569 type two. The NCW received only 176 replies to the 580 questionnaires sent to general hospitals. It attributed its poor response to the fact that busy matrons were faced with two detailed questionnaires.94 The College gained twofold not only because it retained control of its agenda but also because the fact that its report was based on more replies increased its authority. The NCW questionnaire was designed to establish a link between long hours, inadequate rest, low salaries, unsatisfactory accommodation, medical care facilities and the poor physical health of nurses.95 In comparison, the College maintained a much narrower focus of investigation by simply measuring the number of hours worked, time allocated to meal breaks, the quota of staff on duty, type of accommodation and salary. It drew no conclusions about the possible 88

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impact on nurses’ health. For example, in response to evidence that a nurse from a private nursing home had sleeping quarters in a converted mews where horses were kept on one side and three nurses in a converted cubicle on the other, the College recommended that all nurses should have separate bedrooms.96 Only two lines of its twenty-­ seven-­page final report referred directly to nurses’ health and that was a rather vague recommendation that ‘definite steps should be taken to ensure nurses not going on duty when unfit to do so’ but it failed to specify what these steps should include.97 The NCW, on the other hand, argued that shared bedrooms and bathrooms involved a health risk because of the lack of good quality of air. It also encouraged high standards of personal hygiene to reduce the risk of contracting infection by recommending that nurses take a daily bath, in a bathroom not shared by more than four people, and with a maximum time allowed of fifteen minutes per nurse.98 The NCW took a much broader view of nurses’ work conditions than the College by attempting to measure nurses’ sickness levels. It asked hospitals for details of their average percentage of nurses’ sickness, the average number of breakdowns in each year of training and the most common causes of sickness.99 The term ‘breakdown’ referred to an episode of illness that caused the nurse to take time off work. Whether the College refused to work with the NCW because it anticipated revelations of high levels of nurses’ sickness is unknown. If so, its fears were unfounded as the NCW found sickness levels lower than it expected. In fact, levels were ‘far below that which is taken by insurance societies as a general rate to be expected amongst healthy women of corresponding age’. The NCW blamed hospitals’ poor record keeping for these results, which, it argued were ‘were not a true depiction of nurses’ health’. More than half of responding hospitals admitted that they were not able to identify the common causes of sickness because of a lack of records.100 In 1919, an American study of student nurses’ health by Elizabeth Miller also reported a lack of records but suggested this was caused by hospitals’ reluctance ‘to state authentically the number of sick days and minor illnesses and conditions’.101 Miller argued that hospitals ignored nurses’ health because of the tradition that equated ill-­health with evidence of lack of physical endurance. She suggested that, because pupil nurses were regarded as cheap, expendable labour, 89

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hospitals showed little interest in their health problems.102 Poor record keeping also illustrates how new the concept of occupational health was to some sections of the British and American workforce. Only one large British hospital, out of the 176 who responded to the NCW survey, kept an accurate record of the average number of ‘breakdowns’. This hospital recorded a high sickness rate with ‘one in every fifteen nurses always off duty owing to ailment’. It found that twice as many probationers broke down in the first year of training as in the second, and episodes of illness were more numerous in the second than the third. The NCW concluded that third-­year probationers ‘represented the very strongest’. The number of breakdowns was much higher than it should be, the NCW argued, considering the high standard of health required to pass the hospital’s medical examination at the start of training.103 Despite its evidence to the contrary, the NCW concluded that Under the present system of training at nearly all hospitals an alarming percentage of Nursing Students are disabled, and of those who complete their training an even higher percentage contract permanent physical troubles, with the result that a large number of women are left with decreased powers of useful work, and, incidentally, with their position as potential mothers seriously prejudiced.104

For the most part, the NCW’s report discussed nurses’ health in generalised terms, such as ‘breakdown’ or ‘below the ideal’. The only two specific health risks identified were constipation and a potential risk to future reproductive health. Constipation was linked to a lack of toilets and insufficient time to go to the lavatory between breakfast and reporting on duty. The NCW’s claim that nursing jeopardised women’s reproductive ability was more serious and was made without any reference to scientific evidence of either miscarriage or infertility problems among nurses. Indeed, its questionnaire did not investigate nurses’ gynaecological histories. The claim undermined one of the foundations of Victorian nursing ideology, the idea that women’s natural role as mothers qualified them to nurse. This chapter has already discussed the ways the College of Nursing’s supporters shaped this ideology to support their argument against the restriction of nurses’ working hours. The NCW was exploiting early twentieth-­century concerns about high maternal mortality rates among fit young women.105 In 1906, the 90

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rate stood at forty-­two deaths per 10,000 births and was still at forty-­ two in 1932 despite the introduction of a number of measures that should have reduced the risk. It was the second most common cause of death among women of childbearing age, after TB. The First World War and concerns about the heavy, unpleasant and risky nature of much factory work raised anxieties about maternal and foetal welfare, centring not only upon the current generation of mothers but also on young women workers, Britain’s future mothers.106 These anxieties dovetailed with a growing interest in the youth of both sexes and concerns about the role of young people in preserving the interests of the state and the social and moral fabric of society as future parents.107 A number of influential reports analysed the relationship between work and women’s health, focusing on issues of female physiology and maternity, notably the War Cabinet Committee Report on Women in Industry of 1919.108 Reports of the HMWC, the Factory Inspectorate and journals and health advice literature discussed the future role of young working girls as mothers. By 1920, maternal health had become a public and political affair, debated by the medical profession and government as well as the general public in the medium of the daily press and women’s magazines.109 What was new about the NCW’s claims was that they were made about a supposedly middle-­class occupation of single women with an image of superior morality. Many aspects of nursing stood in opposition to the stereotypical image of the frivolous, shopaholic working-­class worker identified as a reproductive risk at the end of the nineteenth century.110 Nursing, dominated by middle-­class leaders, continued to see the recruitment of ‘respectable’ middle-­class women as a way of raising its status even after the Registration Act. Discipline and moral respectability were core tenets of its ideology. For example, rules regarding male visitors remained strict in the first quarter of the twentieth century: In most hospitals it is the rule that of the male sex only fathers and brothers may be entertained by the Nurses, on no account may a Student call, and it is rarely rendered possible for a male friend to be entertained – that a man should call in the evening is almost unheard of.111

Nurse organisations affiliated to the NCW may have been convinced that registration was finally within their grasp, and, buoyed 91

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up by confidence from the praise nurses’ war work had received, felt it no longer necessary to link the ideology of motherhood with their bid for professional status. The risk of exposing the contradictory nature between maternalism and professionalism diminished. For, as Woolacott notes, professionalism ‘meant that women did not define themselves as mothers, that they chose not to stay at home even part of the day, that they had a range of skills and abilities comparable with men’s, and that they sought to participate within the masculine public sphere’.112 Although the NCW’s report concluded by stressing the ‘need of drastic revision of the present conditions under which students work’, it had little impact on nurses’ health care.113 Researching an article on work conditions for the Woman’s Leader, Dr Herbert Crouch, instigator of the NCW’s investigation, was Curious to know whether the report of the National Council of Women … had had any effect, he wrote to a large hospital to ask whether nurses’ hours of duty had been improved. He was informed that the hours were being investigated but the badminton and tennis clubs had been instituted.114

With far fewer replies than the College of Nursing, the NCW was not able to offer an authoritative overview of nurses’ work conditions. The College’s report confirmed that its priority was to retain the support of hospital management by convincing them that it had no intention of insisting on government legislation on its recommended scale of salaries. The College wanted to continue the existing system whereby salaries were set at employers’ discretion. It used its report to promote an image of nurses as uninterested in financial gain per se but worthy of financial reward as a reflection of professional status. Conclusion The growth in health and welfare measures for women factory workers during the First World War did not reach the nursing profession. Few voluntary hospitals could afford to implement workers’ welfare schemes. An abundant supply of nurses following the war, supplemented by an influx of VADs, meant that hospitals were able to replace sick nurses with healthy recruits and were not forced to improve nurses’ welfare or work conditions as a way of attracting 92

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or retaining recruits. Their power to set their own conditions of work plus nurse organisations’ determination to belong to a self-­ governing profession explains why the health care of nurses began to be perceived as falling below the standard offered to some workers in private industry. The Registration Act did not improve nurses’ work conditions or address issues related to nurses’ health. The bitter rivalry and disagreement between nurse organisations, which characterised the campaign for registration, intensified in 1919 as each fought to achieve overall control of the registration process and its governing body, the General Nursing Council. This history of disagreement, and the College and Central Committee’s failed attempts to introduce their own bills of registration, allowed Addison, Minister of Health, to gain control of registration’s agenda and exclude linked economic benefits. Such was nurse organisations’ determination to gain professional status that they accepted his terms. Addison was aware of nurses’ poor work conditions but saw no advantage in linking improvements to work conditions to registration. His aim was to have a list of trained, competent nurses that could aid the organisation of the newly created Ministry of Health. Any expectations that registration would automatically lead to improved work conditions were squashed by government from the outset. The government’s decision to prohibit discussion of economic conditions in connection with registration may have been driven by its intention to include nurses in legislation aimed at improving work conditions for all class of workers. Nurse leaders’ refusal to co-­operate can partly be understood in class terms. Elitism, social status and a sense of superiority shaped nurse leaders’ belief that nurses should not be bracketed with working-­class domestics for fear that this would undermine their newly gained professional status. Membership of a professional occupation involves more than gaining a registration certificate, and these nurse leaders were determined to belong to a group with socially-­defined boundaries. Although registration had given trained nurses the credentials to claim professional status, nurse leaders were concerned with the occupation’s social standing and the need to demark its boundaries and discriminate ‘insiders’ from ‘outsiders’. The College of Nursing was caught in a difficult place in 1919. 93

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Although it aimed for better conditions for nurses and realised the necessity for action, its determination to be a self-­governing organisation, compounded with its concern not to respond like a trade union, saw nurses excluded from early state efforts to improve the lot of workers. The College wanted to retain voluntary hospitals’ support, leading it to oppose the imposition of standard scales of pay and working hours. Its members continued to uphold the notions of self-­sacrifice and dedication to duty not only as necessary qualities to nurse but also as justification for the length of working hours. Its authority to investigate nurses’ health was undermined by criticism that it was partly funded by perpetuating an image of the nurse as an object of charity. The College’s refusal to form a joint enquiry with the NCW was not because it wanted to distance itself from the NCW’s politics but more because it feared being drawn into contentious issues at a time when the question of registration hung in the balance, particularly as the Minister of Health’s determination to exclude economic improvements from registration’s agenda made the issue of work conditions politically sensitive. Despite the attention it received, the health of nurses was of low political priority in 1919. Government’s strategies to control registration’s agenda and nurse organisations’ refusal to co-­operate in its subsequent legislation programme left nurses’ health care uncontrolled and in the hands of individual hospitals, many of who were in dire financial straits. The next chapter will examine how revelations in the 1930s that nurses were at high risk of contracting TB forced the government, nurse organisations and hospitals to consider legislating nurses’ health care. Notes 1 Nursing Times (5 July 1919). 2 Rafferty, The Politics of Nursing Knowledge, p. 78; Summers, Angels and Citizens, pp. 237–70. 3 Rafferty, The Politics of Nursing Knowledge, p. 77. 4 Ibid.; Dingwall et al., An Introduction to the Social History of Nursing, p. 86. 5 D. Beddoe, Back to Home and Duty: Women Between the Wars 1918–1939 (London: Pandora, 1989), pp. 132–47; S. Bruley, Women in Britain since 1900 (Basingstoke: Macmillan, 1999), pp. 59–91; M. Pugh, Women and the Women’s Movement (Basingstoke: Macmillan, 1992), pp. 43–70.

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The Nurses’ Registration Act 6 S. McGann, A. Crowther and R. Dougall, A History of the Royal College of Nursing 1916–90: A Voice for Nurses (Manchester: Manchester University Press, 2009), p. 41. 7 P. Clark (ed.), The Cambridge Urban History of Britain (Cambridge: Cambridge University Press, 2000), p. 618. 8 Harrison, Not Only the ‘Dangerous Trades’, pp. 113–24. 9 RCN, RCN/4/1919, The College of Nursing, Report of the Salaries Committee on Salaries and Conditions of Employment of Nurses (April 1919), pp. 15–16. 10 The Nursing Times (5 July; 15, 22 November; 27 December 1919); The Nursing Mirror and Midwives Journal (23 August 1919); BJN (4 October 1918; 18 December 1920). 11 McGann et al., A History of the Royal College of Nursing, p. 63. 12 M. Baly, Nursing and Social Change (London: Routledge, 1995), p. 164. 13 K. O. Morgan, ‘Addison, Christopher, first Viscount Addison (1869–1951)’, Oxford Dictionary of National Biography (Oxford: Oxford University Press, 2004). 14 E. J. C. Scott, ‘The influence of the staff of the Ministry of Health on policies for nursing, 1919–1968’ (PhD dissertation, London School of Economics, 1994), p. 31. 15 Dingwall et al., An Introduction to the Social History of Nursing, p. 86. 16 Public Record Office, London (hereafter PRO), MH 55/462, ‘The establishment of the General Nursing Council’, memorandum to Dr Christopher Addison, 1 October 1919, p. 1. 17 Scott, ‘The influence of the staff of the Ministry of Health’, p. 31. 18 Rafferty, The Politics of Nursing Knowledge, p. 90. The Association of Hospital Matrons was set up in 1918 as a rival College of Nursing-­backed organisation to the Gordon Fenwick-­led Matrons’ Council of Great Britain and Ireland. Membership was open to trained nurses who held or had held the position of matron or superintendent of hospitals and institutions concerned with the training of nurses and the care of the sick. Rafferty argues that it was created to capture as much representational power as possible. 19 Abel-­Smith, A History of the Nursing Profession, p. 82. Represented on the Central Committee for the State Registration of Nurses, set up in 1908, were the Royal British Nurses’ Association, the Matrons’ Council of Great Britain and Ireland, the Society for the State Registration of Nurses, the Fever Nurses’ Association, the Association for Promoting the Registration of Nurses in Scotland, the Scottish Nurses’ Association, the Irish Nurses’ Association and the Irish Nursing Board, the Infirmary Nurses’ Association and the British Medical Association. 20 Rafferty, The Politics of Nursing Knowledge, p. 80. 21 Ibid., pp. 85–6. 22 Ibid. 23 The Times (6 June 1919), 8.

95

Who cared for the carers? 24 Abel-­Smith, A History of the Nursing Profession, p. 26. 25 PRO, MH 55/462, minutes of meeting with Sir Robert Morant and Association of Hospital Matrons, 17 October 1919. 26 PRO, 55/462, memorandum from Addison, ‘The establishment of the General Nursing Council’, 1 October 1919. 27 Ibid. 28 Rafferty, The Politics of Nursing Knowledge, p. 91. 29 Ibid. 30 PRO, 55/462, memorandum from Addison, ‘The establishment of the General Nursing Council’, 1 October 1919. 31 McGann et al., A History of the Royal College of Nursing, p. 58. 32 R. Lowe, ‘Hours of labour: negotiating industrial legislation in Britain, 1919–1939’, Economic History Review, 35:2 (1982), 256. 33 McGann et al., A History of the Royal College of Nursing, p. 58. 34 Ibid. 35 BJN (18 December 1920), 340. 36 BJN (15 January 1921), 36. 37 RCN, RCN/2/2, minutes of council meeting, 8 April 1920. 38 Nursing Mirror and Midwives Journal (8 November 1919), 96. 39 The Royal College of Psychiatrists’ spirituality and psychiatry special interest group, Spirituality and Mental Health Leaflet, June 2006, www.rcpsych.ac.uk/ mentalhealthinfo/treatments/spiritualityandmentalhealth.aspx. Accessed 28 June 2012. 40 BJN (6 November 1920). 41 Ibid. 42 Ibid. 43 Sandhurst Report, p. 295. 44 BJN (21 October 1911). 45 G. Hecker, ‘The overstrain of nurses’, BJN (1 March 1919), 134–5. 46 Cooper and Dewe, Stress: A Brief History, pp. 2–5. 47 Ibid. 48 BJN (24 August 1912). 49 BJN (26 October 1912), 330–2. 50 RCN, RCN/2/2, College of Nursing council minutes, Vol. 3 (8 April 1920), pp. 1–10. 51 Nursing Mirror and Midwives Journal (5 July 1919), 258. 52 RCN, RCN/2/3, letter to G. C. Anderson, deputy medical secretary, BMA, from M. S. Rundle, secretary to the College of Nursing (23 March 1920). 53 Nursing Mirror and Midwives Journal (5 July 1919), 258. 54 Ibid. 55 A. Marsh and V. Ryan, Historical Directory of Trade Unions: Non-­Manual Unions (Aldershot: Gower, 1987), p. 184. 56 Rafferty, The Politics of Nursing Knowledge, p. 87.

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The Nurses’ Registration Act BJN (1 November 1919), 266. BJN (15 November 1919). ‘An unjust tax’, BJN (26 March 1921), 177. BJN (15 January 1921), 36. Abel-­Smith, A History of the Nursing Profession, p. 257. BJN (15 January 1921), 37. J. Hicks and G. Allen, ‘A century of change: trends in UK statistics since 1900’, House of Commons Library research paper (21 December 1999). www.parliament.uk. Accessed 20 February 2012. 64 BJN (15 January 1921), 37. 65 A. Digby, The Evolution of British General Practice, 1850–1948 (Oxford: Oxford University Press, 1999), pp. 318–22. 66 Ibid. 67 RCN, RCN1/1/1918/2, letter from the College of Nursing Ltd to members, undated. 68 RCN, RCN/1/1/1918/2, letter from M. S. Rundle, secretary to the College of Nursing, to hospital matrons, 12 October 1921. 69 BJN (15 January 1921). 70 Ibid. 71 BJN (28 February 1920). 72 McGann et al., A History of the Royal College of Nursing, p. 21. 73 Nursing Times (15 November 1919), 1218. 74 BJN (August 1924), 190. 75 BJN (21 February 1920), 115. 76 Nursing Times (15 November 1919), 1218. 77 RCN, RCN/26/6/23, The Royal National Pension Fund for Nurses, Report of the Thirty-­Fourth Annual General Meeting, 23 June 1921, p. 2. 78 McGann et al., A History of the Royal College of Nursing, p. 56. 79 RCN, RCN/29/2/3, Report of the council meeting and conference of the NUWW, 8–10 October 1918. 80 RCN, RCN/29/2/3, College of Nursing council minutes, 21 June 1918. 81 Ibid. 82 RCN, RCN/29/2/3, College of Nursing council minutes, 20 June 1918. 83 RCN, RCN/1/1/1919/1, Correspondence of Arthur Stanley, March 1919. 84 ‘Nurses’ hours and pay’, letter from M. M. Ogilvie Gordon, President of the National Council of Women, The Times (25 March 1919), 10. 85 RCN, RCN/29/2/3, letter from M. S. Rundle, secretary to the College of Nursing Ltd, to M. M. Ogilvie Gordon, 4 February 1919. 86 RCN, RCN/29/2/3, letter from M. S. Rundle, secretary to the College of Nursing Ltd, to M. M. Ogilvie Gordon, 12 March 1919. 87 The Times (25 March 1919). 88 McGann et al., A History of the Royal College of Nursing, p.57. 89 BJN (18 October 1918). 57 58 59 60 61 62 63

97

Who cared for the carers? 90 BJN (19 October 1918). 91 BJN (27 September 1919). 92 Ibid. 93 RCN, RCN/4/1919, Report of the Salaries Committee on Salaries and Conditions of Employment of Nurses (April 1919). 94 BJN (27 September 1919). 95 NCW, ‘Report of the special committee on the economic position of nurses’, BJN (27 September 1919), 189–94. 96 RCN, RCN/4/1919, Report of the Salaries Committee, p. 11. 97 Ibid., p. 3. 98 NCW, ‘Report of the special committee on the economic position of nurses’, BJN, (27 September 1919), 190. 99 Ibid., 192. 100 Ibid., 189. 101 Nursing Times (11 October 1919). 102 E. F. Miller, ‘Conditions which influence the health of student nurses’, The American Journal of Nursing, 19:10 (July 1919), 757–63. 103 NCW, ‘Report of the special committee on the economic position of nurses’, BJN (27 September 1919), 192. 104 Ibid., 189. 105 I. Loudon, ‘Maternal mortality: 1880–1950: some regional and international comparisons’, Social History of Medicine, 1:2 (1988), 183–228. 106 J. Pickstone, ‘Production, community and consumption: the political economy of twentieth-­century medicine’ in R. Cooter and J. Pickstone (eds), Companion to Medicine in the Twentieth Century (London: Routledge, 2003), pp. 1–20. 107 V. Long and H. Marland, ‘From danger and motherhood to health and beauty: health advice for the factory girl in early twentieth-­century Britain’, Twentieth Century British History, 20:4 (2009), 454–81. 108 PRO, LAB 5/3, Reports from the War Cabinet Committee on Women in Industry (Cmd 135 and 167, 1919). 109 Loudon, ‘Maternal mortality: 1880–1950’, 183. 110 C. Malone ‘Gendered discourses and the making of protective labour legislation in England, 1830–1914’, Journal of British Studies, 37: 2 (April 1998), 166–91. 111 RCN, RCN/4/1919, Report of the Salaries Committee (April 1919), p. 11. 112 A. Woolacott, ‘Maternalism, professionalism and industrial welfare supervisors in World War I Britain’, Women’s History Review, 3:1(1994), 31. 113 NCW, ‘Report of the special committee on the economic position of nurses’, BJN (27 September 1919), 192. 114 BJN (18 December 1920), 341.

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4

‘The disease which is most feared’:1 the problem of tuberculosis and its threat to nurses’ health, 1880–1950

‘The disease which is most feared’

In 1882, Dr Theodore Williams of the Brompton Hospital for Consumption concluded that tuberculosis posed little danger to nurses as long as they took proper precautions handling sputum.2 At the time TB, or consumption as it was widely known, was the largest single recorded cause of death in Britain with an annual death toll of over fifty thousand.3 As its incidence in the general population declined during the first half of the twentieth century, its threat to nurses’ health increased. Indeed, in 1945, the King Edward’s Hospital Fund recommended that urgent action was needed to reduce its risk.4 This chapter examines why TB was perceived as a hazard to the health of nurses in the 1930s and 1940s and not before. From 1925 onwards, a number of national and international studies identifying TB as a significant occupational risk for general hospital nurses appeared in the medical press. General nurses were believed to be at a higher risk than their sanatoria counterparts, particularly in the first year of training. The studies initially made little impact but, I want to argue, the chronic shortage of nurses throughout the 1930s created a sense of urgency, stimulated further research and propelled the problem of TB amongst nurses into wider political, social and medical debates. Historical analysis has paid little attention to the risk TB posed to nurses. This is surprising considering that several hospital-­associated outbreaks of infection during the 1980s and 1990s, particularly involving HIV-­infected individuals, drew attention to the dangers of infection to nurses. High-­risk nurses are now considered to be those working in respiratory clinics, intensive care and emergency departments and all those who work regularly with TB or HIV-­positive 99

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patients.5 Sue Hawkins concludes that very few nurses from St George’s Hospital, London, were diagnosed with TB in the late nineteenth century. This low rate, she explains, may have been because cases were misdiagnosed as bronchitis or because they were deliberately hidden because of TB’s stigma. Doctors wanted to protect nurses and their employing hospital from the shame attached to it.6 The true incidence of TB is unknown, Hawkins argues, ‘hidden among the nurses who left under the general category of breakdown in health’.7 However, it is difficult to gauge the level of nurses’ risk without knowing the number of TB patients admitted to St George’s. Although TB patients were often passed over to the poor law system, this chapter suggests that a significant number gained admission to voluntary hospitals, often undiagnosed. Stephanie Kirby’s analysis of sanatoria nursing between 1920 and 1970 argues that sanatoria were considered safe spaces for nurses where the risk of contracting TB from patients was reduced by the spacious nature of the buildings and the fresh air and plentiful food available to strengthen their defences. Her focus on nursing care excludes examination of TB rates among sanatoria nurses in this period.8 Although historians of mental health nursing have noted that TB was a common ailment among asylum patients in the early twentieth century, there has been little interest in its impact on the health of asylum nurses. For example, Geertje Boschma’s history of four Dutch asylums notes that the number of patients dying from TB was considerably higher than in the population at large. Crowded institutions and patients’ physical weakness facilitated the spread of disease, according to Boschma, but she does not examine its affect on nurses.9 By the early twentieth century, TB was recognised as an occupational health risk in some industries where the nature of work and working conditions were acknowledged as important factors in its epidemiology. For example, in 1915, the Medical Research Council concluded that high TB rates in the boot and shoe trade were the result of a failure to attract robust workers and a lack of ventilation. The quality of air was considered very important to both the cause and the treatment of TB, but scientific and medical interest in air quality and diseases centred on the home not the workplace or outdoors.10 Industries with high TB rates were those with a pneumoconiosis risk, which predisposed workers to TB. Dust, racial disposition 100

‘The disease which is most feared’

and the tendency of workers to intermarry were also proffered as explanation of the high TB rates in the north Wales slate industry.11 Commentators frequently focused on an employee’s personal habits, supporting the notion that TB was a social problem.12 For example, barmen experienced a higher than average incidence of TB, which was thought to be related to their easy access to alcohol and tendency to over indulge.13 Medical knowledge about contagious diseases was in its infancy in the late nineteenth century. Whereas today TB is recognised as an infectious disease caused by mycobacterium tuberculosis and scientists agree that malnourishment, health work, silicosis and long-­term drug or alcohol abuse increase individual susceptibility, there was a lack of consensus about its meaning and properties a centenary ago. After Robert Koch discovered the tubercle bacillus in 1882 and found that it was infectious, a new medical science was formed based on bacteria and scientific analysis. However, although acceptance that tubercle bacillus played a role in the disease grew rapidly, uncertainty as to why most infected people remained healthy allowed a complex series of debates to flourish, which Michael Worboys argues became less rather than more settled over time. While most physicians accepted the reality of Koch’s bacillus, they debated its meaning and tried to fit its properties into existing ideas of contagion and their clinical experience. The lack of consensus amongst doctors hampered policy innovation regarding occupational health. Lancashire cotton workers’ petitions to ban practices associated with TB failed because of lack of medical support.14 The theme of class was important in shaping general conversations about TB. Katherine Ott traces the disease’s cultural transformation in America from 1870. She describes the changing layers of meaning that surrounded its diagnosis, and how, among the middle classes, this ‘most flattering of all diseases’ was, as awareness of the social associations grew in the 1880s, transformed into a disease that was the consequence of acquired or inherited degeneracy and confined to the poor, working class. The demographics of consumptive mortality, Ott argues, had been invisible when the disease was understood as an expression of the inner life of upper-­and middle-­class white Americans. The linchpin of the change from middle-­to working-­class disease was the new understanding of TB as an infectious disease. It 101

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eroded the belief that explained TB in terms of an individual’s constitution and, as a result, the disease became an issue of civic order.15 After decades of comparative lack of interest, medicine, the state and public health services mobilised a major co-­ordinated campaign against TB in Britain from 1900. This sudden interest, Lynda Bryder argues, was prompted by concern for national efficiency rather than the discovery of the tubercle bacillus. Whilst the question of who was most likely to contract the disease remained unresolved, there appeared to be certain indisputable trends confirmed by mortality statistics, that TB was a disease of poverty and associated with poor working-­class areas. Commentators disputed which aspects of life were responsible, mooting overcrowding, insanitary living conditions, malnourishment or ‘bad habits’ as possibilities. Bryder highlights how TB patients were stigmatised, and often rejected by family and friends; if they survived, they hid their past from insurance companies, employers or spouses.16 Gender is an important theme to understandings of nurses’ occupational health, and initial investigations suggested that it would underpin understandings of why TB was a problem for general nurses. Young women’s growing susceptibility to the disease, indicated by slight increases in the TB mortality rates for females aged fifteen to twenty-­five during the First World War and the 1920s, has been explained by a number of factors. Writing in 1947, nurses Olive Buxton and P. M. Mackay suggested that the causes were a biological predisposition caused by the fact that ‘females tend[ed] to mature earlier than males and the responsibilities of life felt at an earlier age’ combined with ‘endocrine gland disturbances during puberty’.17 Bryder considers other possible causes including women’s emancipation and changing social habits and lifestyle from 1900, particularly employment in industry and entry into competitive wage earning. Certainly modern life was believed to be damaging young women of all classes but it was a contentious explanation of disease that was by no means straightforward, or unquestioned. Notions of class not only shaped understandings of TB during the interwar years but also influenced conversations about the recurrent crises in nurse recruitment, which elevated nursing into an issue of the highest priority.18 Towards the latter half of the 1920s, concern began to grow that the supply of nurses was insufficient to meet the 102

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demand for nursing labour.19 As more acute sickness was treated in hospitals, so the demand for nurses increased.20 However, some contemporary commentators considered that the shortage was due to the decline in nursing’s ability to attract well-­educated, and hence almost inevitably, middle-­class recruits.21 Assumptions that nursing was losing ground to other middle-­class professions such as teaching and social work have been challenged by recent research suggesting that competition was coming from ‘low-­level white collar posts in the commercial sector – clerks, typists and shop assistants’.22 What was said about education, Brian Abel-­Smith argues, was really a polite way of making statements about social class.23 Abel-­Smith’s contention that nurses’ social background began to change in this period, as more were drawn from the lower middle and working classes and fewer from the upper classes,24 has been challenged by recent research suggesting that it was unlikely that nursing ever did recruit widely from the middle classes.25 This chapter examines whether TB was considered an occupational health problem among nurses at The London Hospital, which had no recruitment problems in the 1930s and 1940s compared with the South Devon and East Cornwall Hospital and the Cornwall Lunatic Asylum, which recorded frequent shortages. It compares how each hospital cared for nurses suffering from tuberculosis and identifies the factors that shaped their treatment. However, it will start with an assessment of nurses’ risk of TB before 1925. No health risk to nurses Until the mid-­1920s, the general consensus amongst doctors was that TB posed little threat to nurses. This opinion was based on the work of Dr Theodore Williams of the Brompton Hospital for Consumption, who published two influential studies in 1882 and 1909. Williams examined the incidence of TB amongst all resident staff at the Brompton from 1848 and 1888, and found low levels of disease among nurses. Their susceptibility was hereditary, according to Williams, and not influenced by contact with infectious patients. None of the six matrons, who slept in rooms next to the wards, had contracted TB during his study. Between 1842 and 1867, five nurses out of an unknown total died from the disease, and, from 1867, only 103

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one nurse out of 101. Williams attributed one death to ‘poverty after leaving the hospital’ and another to the nurse’s marriage to a consumptive patient.26 These were factors connected to personal responsibility rather than contact with a contagious disease. Of the other groups of hospital workers studied, dispensers, who had the least contact with patients, showed the highest proportion of consumptives (9.61 per cent) whilst the nurses and female servants, who had the closest contact, had the lowest (0.98 per cent). Resident medical officers (3.76 per cent) and porters (4.18 per cent) were more affected than nurses.27 Facing criticism of incomplete data and poor record keeping, Williams in 1909 updated his findings, which had become influential, entering the standard medical texts of the day as evidence of the comparative immunity of hospital staff from tuberculous infection. An American pulmonary textbook, written in 1924, stated ‘there is no danger from the expired air of consumptives. For this reason a tuberculosis sanatorium is probably the safest place one can be so far as the danger of infection is concerned’.28 Nurses were not included in Williams’s later study because of the rapid turnover of staff. Among the few who had been in post for at least twenty years, phthisis was ‘almost unknown’. (Phthisis means a wasting disease but commonly referred to pulmonary tuberculosis in the nineteenth and early twentieth centuries.) Williams concluded that it was the ‘individual strength of constitution, on which mainly depends the question of infection or non-­infection … The healthy individual can defy the tubercle bacillus, the same person depressed by want, impure air or recovering from acute disease cannot.’ As long as the ‘proper precautions’ were taken when handling sputum, Williams argued, there was no danger to health workers.29 In 1910, Williams was severely criticised by Dr Edward Squire, a senior physician at Mount Vernon Hospital, Rickmansworth, Middlesex, for basing his results on inquiries into the health of former residents rather than medical examination.30 Squire’s own fifteen-­ year study (1895–1910) of 167 nurses at Hampstead Hospital and five-­year study of sixty-­eight nurses from Northwood Hospital (both TB hospitals) concluded that the ‘risk of infection in hospital is not entirely a negligible quantity, though the risk is a small one and affects the nurses and servants of the institution 104

‘The disease which is most feared’

rather than members of the resident medical staff’.31 Squire’s study was based on the results of medical examination, including X-­rays, on commencing and leaving employment at the hospitals. The majority of nurses included in the study were general hospital probationers, who had been seconded to the TB hospitals for one of their three years of training. The risk of infection was from specific nursing tasks, Squire concluded, such as cleaning sputum cups and flasks and handling soiled handkerchiefs, clothing or bedding, and not from direct infection from the patient. Contracting infection ‘directly from patients coughing or from general air infection from dried sputum should be practically non-­existent in the wards of a well-­ordered hospital’.32 Squire believed order and discipline to be a key part of infection control. In contrast to future studies, Squire found that nurses with no previous nursing experience were least likely to develop TB. The threat to nurses’ health, 1924–32 The idea that TB posed a significant health risk to general nurses was strengthened by the work of Norwegian Dr Johannes Heimbeck in 1924. Indeed the Lancet identified Heimbeck as a pioneer in devising an accurate measurement of the risk nurses faced from TB. Heimbeck serially tested 420 student nurses in Oslo on entry into nursing and then annually in order to establish the tuberculin skin test conversion rate as well as the development of active tuberculosis.33 The development of tuberculin skin tests in the early twentieth century facilitated Heimbeck’s research. Austrian scientist Clemens von Pirquet developed a cutaneous test in 1907 that involved dropping tuberculin on cleaned skin that was subsequently scratched. A person who had not yet become infected experienced no reaction at the site of the scratch, whilst an area of redness and swelling demonstrated evidence of previous infection. In the same decade, French physician Charles Mantoux introduced the intradermal technique, allowing the administration of an exact dose of tuberculin with a needle and syringe.34 Heimbeck reported that, of the 420 student nurses studied, 220 were tuberculin-­negative at entry but skin tests had converted positive in 210 (95 per cent) by the end of training.35 Forty-­eight (22 per cent) cases of clinical tuberculosis occurred in this group compared 105

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with three (1.5 per cent) in the 200 initially tuberculin-­ positive nurses. By 1946, 105 (37 per cent) of 284 initially tuberculin-­ negative nurses had developed active tuberculosis. Heimbeck concluded that tuberculous risk was much greater if nurses converted from tuberculin-­negative to positive during training than if they were already positive on entry.36 The decline in the prevalence of TB in the general population meant that many nurses had not experienced contact with the disease and therefore had not developed a resistance. Set against this group was a population of older patients with pulmonary tuberculosis. Writing for the American Hospital Association in 1931, Dr David A. Stewart, medical superintendent of Manitoba Sanatorium, explained that At the present time young people in good homes and in careful communities can grow up with scarcely enough acquaintance with tuberculosis infection to build up any defence against it. In a gathering place of tagged and untagged infections, such as a general hospital, such unprotected young people are as sheep among wolves.37

Interest in TB, and particularly its threat to nurses’ health, heightened in the 1930s. The Lancet published at least fifty articles on various aspects of the disease and treatment in 1930. The majority of reports about the risk posed to nurses stemmed from America and Scandinavia.38 For the first time, physicians Theodore Badger and Wesley Spink argued in 1936, the American ‘nursing profession was shown that at least half their students had never been exposed to tuberculosis before entering training and this group were especially likely to develop active tuberculous disease’.39 A Canadian report concluded that ‘it seems unquestionable that nurses are especially liable to contract tuberculosis’.40 Part of the British problem, the Lancet argued, was that hospitals ignored the risk posed to nurses: It is only of late that certain hospitals have squarely faced their responsibilities in relation to the tuberculosis risks run by their nurses. In the past little has been done to determine the exact degree of these risks, and … it is difficult to devise methods to prove whether or not the nursing care of the tuberculous really is a hazardous occupation.41

As in Britain, America’s growing demand for nurses outstripped supply in the 1930s and, as a result, TB amongst nurses gained in importance. When American physician Arthur Myers questioned 106

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whether student nurses should continue to nurse TB patients, comparing their exposure to animal experimentation ‘except that in animal work it is possible to control the dosage and kill an animal at any time’, Dr Maurice Fishberg (chief of the TB service at the Montefiore Hospital and physician to the Bedford Hills Sanatorium, New York) accused Myers of exacerbating recruitment problems.42 The shortage of nurses in Britain was also linked to adverse publicity surrounding nurses’ risk of contracting TB. In 1930 the Lancet published a letter from Dr Esther Carling, superintendent of Berkshire and Buckinghamshire Joint Sanatorium, which predicted an impending crisis in recruitment, particularly in smaller hospitals and sanatoria.43 Carling had been active in the suffragette movement, was a respected doctor and was particularly interested in the treatment of TB and developing sanatoria.44 She campaigned throughout the interwar period to have TB nursing approved for state registration by the General Nursing Council. She also focused on poor work conditions as reason for the lack of nursing staff and predicted that ‘more and more the doctor depends on the nurse; less and less he will find her’.45 Carling’s letter to the Lancet attracted a sympathetic response and, according to Rafferty, prompted the establishment of the Lancet Commission in 1932.46 Although the recruitment crisis in general nursing was a matter of great concern, the shortage appeared much more dramatic in the TB hospitals, which suffered not only from the stigma of possible infection but also from geographical ­positions on out-­of-­town sites with poor public transport. The Lancet Commission’s remit was to establish reasons for the shortage of nurses and to recommend how to make nursing more attractive to suitable women. It interpreted the cause of the shortage, not as a case of demand increasing faster than supply, but as the result of competition from occupations offering better salaries and career prospects.47 The risk of TB was not mentioned. Indeed, nurses’ health did not feature in the commission’s Final Report based on 686 replies to 1,031 questionnaires sent to hospitals in England and Wales. Shortages of all grades of staff were reported in all types of hospital, most marked in those not approved as training schools and least acute in the London voluntary hospitals.48 To counteract the effects of wastage, the commission heard how hospitals had to re-­ recruit half their establishment of probationers in order to replenish 107

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their complement of trainees every year. The greatest part of this loss occurred during the first year of training. Commentators recognised that the first year of training often had a negative impact on health. For example, the Regius Professor of Physic at Cambridge University (1932–35), Walter Langdon Brown, described the first year as ‘overweighted’. In a letter to The Times in 1934 he wrote of lecturing to ‘young women obviously suffering from severe physical fatigue. I am clear that a greater mental and physical demand is made at this stage from nurses than from medical students.’49 When the Lancet Commission recommended that the minimum age of entry be lowered to seventeen, as a solution to recruitment problems, opponents contended that younger nurses were susceptible to infections, particularly TB, and emotional strain.50 Grahame Erwin, medical superintendent at Liverpool Sanatorium, reasoned that with experience, as nurses learnt to withstand emotional shocks such as death and haemorrhage, so appetite and weight improved.51 Ethel Gordon Fenwick, determined to restrict entry to eighteen and over, accused the commission of failing to understand ‘the mental and physical strain which they propose to put girls scarcely out of the schoolroom’. Immature girls, she contended, were unsuitable for the strain of hospital life.52 Mental hospitals were finding it even more difficult to recruit staff than the voluntary hospitals but not to the same degree as fever hospitals. They also experienced much greater wastage rates. Fourteen per cent of voluntary hospital probationers left training between 1928 and 1930 compared to 30 per cent of mental hospital trainees. ‘Unsuited for a nurse’s life’ and ‘wanted at home’ were the most common reasons given by voluntary hospital nurses for leaving compared to mental nurses’ choice of a ‘desire for a change of work’. Because of their higher wastage rates, mental hospitals accepted staff with much lower educational qualifications: 61 per cent of voluntary hospital probationers had a secondary or matriculation school ­certificate compared to only 14 per cent of mental nurses. The nature of work differed significantly between the two groups of nurses. Mental hospital nurses spent significantly more time performing domestic duties than their voluntary hospital counterparts. Whilst most London voluntary hospitals provided one ward maid per twenty beds, the majority of mental hospitals (81 per cent) provided 108

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no domestic help on the wards, claiming the cleaning was done by patients. Voluntary hospital nurses also had fewer patients to care for, with an average ratio of one nurse to three patients in contrast to the much higher ratio of one to six in 38 per cent of mental hospitals and one to eight or over, in 32 per cent. Hours of duty differed between mental and voluntary hospital nurses. Some mental hospital patient worked five days a week in shifts of between eleven and twelve hours with no daily time off beyond meal breaks whilst others worked a three-­shift system which involved duties of seven or eight hours. Voluntary hospital nurses worked six or six and a half days a week for nine to ten hours per day from between 7 a.m. and 8.30 p.m. with half an hour for lunch and two or three hours’ free time daily.53 Mental hospital and voluntary hospital nurses received similar rates of pay but the hospitals used different systems of payment. Mental hospitals paid untrained staff £1 12s and trained staff £3 weekly and then deducted a charge of £1 for board and lodging. The majority of voluntary hospitals paid probationers £20 to £25 per annum and trained staff between £50 and £85. No charge was deducted for uniform, laundry and board and lodging. Two-­thirds of voluntary hospitals and three-­quarters of mental hospitals provided separate bedrooms.54 In 1937, as recruitment problems intensified following economic recovery and employment opportunities for women expanded, commentators suggested that the promotion of a relaxation in ­ nurse discipline would detract attention from the problem of TB amongst nurses. For example, Dr Peter Edwards, speaking at a BMA meeting, recommended that nurses be given the same freedom as girls employed in industry.55 National newspapers publicised hospitals’ regimentation, petty rules and tyranny as impediments to recruitment.56 One probationer’s father, writing in The Times, argued that hospitals tried to mitigate their financial difficulties, as a result of their attempts to expand in size and number, by overworking young nurses.57 The treatment of nurses’ minor ailments was identified as important in the early detection of TB but hospitals’ disciplined environment was thought to deter nurses from reporting sick. Dr Sheila Bevington, a psychology lecturer at the London School of Economics, interviewed five hundred nurses at five hospitals in 1943 and concluded, that whilst most were satisfied with the way serious illness was 109

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treated, many were unhappy with ‘the handling of minor ailments and difficulties placed in the way of “reporting sick”’.58 At one hospital, nurses could report sick only at 9 a.m.; if sick at any other time, nurses ‘had to confront Assistant Matrons, of whom some apparently adopted unsympathetic attitudes expressed in the comment “you come here to nurse and not to be nursed”’.59 One nurse, a thirty-­year-­old sanatorium patient, highlighted the importance of reporting minor symptoms of illness in the early detection of TB. Writing in Time and Tide in 1945, her reminiscence of nursing during the early 1930s identified the difficulties of reporting sick as responsible for the high levels of disease: In my hospital days it seemed to be regarded as wrong that a nurse should be ill. Unless her symptoms were alarming she hesitated to report them. One heard of nurses being liable to imagine some of their ills. This often deterred a nurse from admitting to minor but important illnesses. Had there been one person at my training school allocated to take the place of a parent or headmistress, who would take a primary interest in the nurses’ health … many of the nurses now in sanatoria could be nursing today, thereby minimising somewhat the present shortage.60

The idea that nurses exaggerated or imagined their ill-­health prevailed. Grahame Erwin, medical superintendent at Liverpool Sanatorium, argued that it was a product of early nurse training: Some nurses, especially as they receive lectures about diseases with which they are dealing, show a morbid introspection which leads to the exaggeration of trivial symptoms, themselves of no significance, to resemble those of the particular disease, say tuberculosis, which is most feared. A medical examination may be necessary to clear the minds of such fears, but either as a result of this, or of more acute observations of other healthy people, this stage passes and gives way to a confidence that proves more lasting.61

Erwin did not take nurses’ minor illness seriously and yet many commentators emphasised that this type of attitude had to change in order to reduce TB rates. I have discussed how medical attitudes towards nurses’ risk of contracting TB changed during the 1920s and 1930s and argued that the problem attracted attention because of the recurrent crises. I want to narrow my focus now on the relationship between medical attitudes towards TB and recruitment problems at the case study hospitals. 110

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The London Hospital Despite the increased attention given to nurses’ risk of TB in the 1930s, The London Hospital did not protect its nurses by isolating tuberculous patients. Indeed, such patients were nursed on the open ward ‘with the usual precautions, such as separate feeding utensils’. The hospital tried to prevent the admission of TB patients but inevitably a minority slipped through the net and gained entry while waiting for transfer to sanatoria.62 In 1930, 13,611 patients were admitted, of whom fewer than 1 per cent (103) had a diagnosis of TB on or during admission.63 This figure is similar to the admission rate found by an American study, which, in 1939, X-­rayed 3,977 patients on admission to fourteen general hospitals and found that 0.7 per cent had active TB. Although this seems a low rate, the study concluded that it ‘was of considerable significance in the infection of student nurses’.64 This conclusion does not seem to have been borne out at The London Hospital, where, despite the lack of infection control, very few nurses were diagnosed with TB in the interwar years. In 1930 only one nurse was diagnosed with ‘suspected TB’ out of a nursing staff of 697. The experience of Ivy G., the nurse in question, suggests that any nurses exhibiting signs of tuberculosis may have been sent home. Ivy, aged twenty and described as a ‘pale, delicate looking probationer’, was admitted to the nurses’ sick room in June 1930 with an infected finger and rheumatism. The rheumatism cleared up but she continued to suffer from persistent pyrexia. Fever was known to be a symptom of TB as well as night sweats, cough, dyspnoea, haemoptysis and loss of weight. None of these was peculiar to TB and might be absent from individual cases. Dr Rowlands, the physician in charge of sick nurses, could not find anything definite to account for her daily rise of temperature and decided it was inadvisable for her to continue training. It was suspected that she had a tendency to lung trouble but various investigations did not prove this to be the case. It was considered as to whether it might be advisable for her to have sanatorium treatment for a time as a preventive measure but after consulting with her people it was decided that in the circumstances and taking everything into account it would be best to go home to Wales.65

Rowlands’s decision to dismiss Ivy may be explained by the difficulties in diagnosing TB; the clinical features of Ivy’s illness resembled 111

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other chest ailments. A second possibility is that The London Hospital did not want to associate its nurses with a disease linked to the poorer working classes although there is no evidence to support this argument. As mentioned earlier, general discussion about TB in society linked it to malnourishment and poor accommodation, amongst other things. If London Hospital nurses were considered vulnerable to TB, then accusations might follow that the hospital failed to care for its nurses. South Devon and East Cornwall Hospital South Devon and East Cornwall (SDEC) doctors were also reluctant to make definite diagnoses of TB during the 1930s but, in contrast to The London Hospital, did not send nurses home indefinitely. Kathleen P., aged eighteen, ‘was threatened with a TB infection of chest’ in her third year of training,66 first-­year probationer Marie F., aged twenty-­four, suffered a ‘threatened TB infection of the lungs’67 and Cynthia G. had a ‘laparotomy to divide adhesions and calcified gland removal? TB’.68 Kathleen and Marie were given long periods of sick leave but both returned to work. Dr Robinson decided Cynthia was ‘not fit enough to continue training’ after nine months’ sick leave.69 The SDEC experienced a shortage of recruits in 1931, 1932, 1936 and 1937 but had a waiting list in 1934. These shortages were partly due to the hospital’s expansion programme in 1931 and the need to increase its complement of nurses from sixty-­eight to eighty-­ two. The hospital’s general committee argued that it could not afford to raise salaries to attract new recruits because of the increase in the number of salaries needed to staff its expansion programme.70 According to Esther Carling, the reluctance to diagnose TB was tied up with the shortage of nurses as well as the difficulties of diagnosis: So great is the need for nurse labour that diagnostic acuteness is blunted … as regards the girls themselves, there is always the next exam looming ahead. So both the employers and the employed must struggle on to keep the machine going and to maintain necessary status within it. Further symptoms when offered are evasive and explainable. When the crash comes the nurse is sent off for treatment, the hospital’s rush persists, and it seems to be nobody’s business to follow up possible implications.71

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SDEC matron A. S. Dickson (1916–31) considered economic factors the main cause of her recruitment problems. It was not fear of TB, Dickson argued, that put off potential recruits but the cost of purchasing uniforms and textbooks, the £5 deposit paid on entry to training and low salaries. She added the declining birth rate during the First World War and nursing’s inability to bridge the gap between sixteen when girls left school and eighteen, the minimum age of acceptance for nurse training, to her list of contributing factors. The idea that financial obstacles deterred recruits suggests that the social background from which SDEC nurses were drawn had changed from the middle and upper classes that characterised recruits in 1917. Indeed at least half the nurses in this hospital had paid for their training until 1919 when recruitment problems prompted the introduction of a £10 first-­year salary. Staffing the hospital on a budget was an issue in the 1930s and this may explain why nurses were allowed long periods of sick leave and encouraged to return to work. In 1932 Dickson publicised improvements to work conditions as a cost-­effective way of improving recruitment.72 Working hours were reduced and early morning prayers made optional.73 Claims that conditions had improved provoked outrage amongst SDEC nurses, twelve of who wrote anonymously to the local press arguing that conditions remained poor.74 The parents of probationer Phyllis B. withdrew their daughter from training, alleging the hospital had neglected her health through overwork and underfeeding.75 In 1937, a further move to attract recruits involved the employment of extra domestic staff to reduce the amount of cleaning nurses performed.76 A high wastage rate further complicated staffing problems. Between 1930 and 1940, 359 probationers started training but 164 (46 per cent) left before qualifying. This was significantly higher than a national wastage rate of 28–32 per cent.77 No analysis or audit was undertaken of why the rate was so high or what measures the hospital could take to reduce it. Of the 164 who left, thirty-­eight probationers cited illness as their reason for terminating their training. Three of this group were believed to have contracted TB.78 The attitude of SDEC doctors towards the treatment of nurses’ TB changed during the 1940s. Doctors began to make definite and clear-­ cut diagnoses and instead of sending nurses home for long periods 113

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they were now referred to Didworthy Sanatorium. For example, third-­year probationer Margaret B., aged eighteen, was diagnosed with ‘phthisis’ in 1940, admitted as an SDEC in-­patient for four months and then transferred to Didworthy Sanatorium. She did not return to work. Three other nurses were admitted to the sanatorium between 1940 and 1944, staying for lengthy periods of at least six months before returning to work.79 The hospital’s house committee seemed unconcerned about the threat TB posed to staff or patients until 1947 when the high number of patients with pulmonary TB prompted it to recommend that these patients should be sent either home or to a sanatorium. Little action was taken prompting the Nurses’ Representative Council (formed in 1945) to protest a year later about the large number of cases of open tuberculosis still being nursed in the wards.80 Publication in the medical press of the high risk nurses faced from TB seems to have had little impact on infection control policy at the SDEC or The London Hospital but it does seem to have raised nurses’ awareness about their risk of disease. Cornwall Mental Hospital Tuberculosis was a significant health problem at the CMH in the interwar years and, known as ‘captain of the men of death’, commonly headed the mortality list. Pulmonary tuberculosis accounted for 27 per cent of CMH patient deaths, with general paralysis of the insane a close second.81 In September 1931, four nurses, one ward maid and the assistant medical officer were diagnosed with pulmonary tuberculosis. Nurses Carhart and Stevens were admitted to Tehidy Sanatorium and, whilst Stevens recovered and returned to work, Carhart remained ill. She was discharged from Tehidy after six months and offered sick pay of 5s a week. Her employers allowed her to live in a hut at the CMH’s isolation wing and receive treatment from the mental hospital medical staff. After a further six months, there was no improvement in her health and she was given one month’s notice ‘to make other arrangements’. Homeless and too ill to work, Carhart left the hospital to an unknown fate. Assistant matron Sweet also contracted TB but her different treatment suggests that personal wealth and seniority may have been an 114

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influential factor. Sweet resigned from her post following a diagnosis of pulmonary TB and was offered three months’ sick leave with full pay and the value of her emoluments. Like Cahart, she was allowed to live in one of the CMH’s huts but with a different aim, ‘so that she may get up her strength before going to Switzerland for treatment’.82 The Victorian belief that Alpine air had a favourable effect on TB was challenged in the early twentieth century though the Alps continued to attract sufferers. Sweet was advised in Switzerland that she was suffering not from TB but from anaphylaxis caused by the wrongful injection of horse serum administered by CMH doctors.83 Animal experimentation was performed in the late nineteenth and early twentieth centuries in an attempt to identify therapeutic sera for TB. These studies were stimulated by the successful development of serum therapy against a variety of infectious diseases.84 The idea that horse serum acted as a vaccination against TB derived from the work of Henri Spahlinger, a Swiss bacteriologist, who in 1912 discovered a vaccination derived from the blood of black horses.85 Spahlinger’s ideas were unpopular amongst British TB specialists with a few exceptions. In 1937, physicians Eugenie Opie and Jules Freund reported that horse serum was as effective as BCG (see below), protecting the individual for up to two years.86 On hearing the news that she was suffering from anaphylaxis, Sweet instructed a solicitor to take up her case of negligence against the hospital. He claimed that: A deliberate and calculated attempt to hide from our client and her parents the real nature of her illness had been made by the medical officer concerned and who must be solely responsible for the wrongful treatment given to our client … Our client was definitely informed that she was to have at least twelve months’ sick leave with full pay and emoluments yet whilst she was still in Switzerland in a grievous state of health, she received a communication informing her that her engagement had been terminated.87

The hospital did not admit liability and Sweet dropped the case, unsettled. The visiting committee minutes clearly indicate that Sweet was offered three months’ sick leave and not the twelve she later claimed. The case suggests that nurses’ seniority and wealth influenced their care in Cornwall although both nurses were eventually dismissed as a result of their illness. Junior nurses received only a small percentage of their salary as sick pay with no value of their emoluments although 115

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the hospital did pay for six months’ sanatorium treatment. Senior nurses received full pay for three months and the value of their board and lodging. Sweet’s personal wealth provided access to the outdated idea that special climates favourably affected the course of the disease. The case also reveals that some doctors attempted to vaccinate nurses against TB with horse serum in the early 1930s. Whether this type of treatment was offered to all levels of nurse is unclear for there is no record that Cahart received horse serum. Debate about whether nurses should be vaccinated continued throughout the 1930s and 1940s. Vaccination Following Koch’s discovery of the tubercle bacillus in 1882, attempts were made to produce an anti-­tuberculous vaccine. Koch himself worked on a vaccine as well as Emil von Behring, a German professor of bacteriology and American Edward Livingstone Trudeau, a tuberculous specialist. The one apparent success story among all these attempts was that of Leon Calmette and Camille Guerin who discovered the bacillus Calmette-­Guerin (BCG) vaccination in France in 1921. British scientists showed little interest in BCG vaccination during the interwar years. Suspicion stemmed from the fear of an unreliable and infective serum, especially after the accident in Lübeck, Germany, in 1930 when seventy-­two infants out of a group of 251 died as a direct result of being given the vaccine.88 In the 1920s the Medical Research Council’s own research workers rejected BCG as unreliable. Public health authorities were not convinced that evidence from Scandinavia supported the vaccination. Frederick Heaf, Professor of Tuberculosis at the Welsh National School of Medicine, highlighted the absence of controlled trials and the difficulty in separating anti-­TB measures such as general hygiene. Alongside scientific objections to BCG, there were administrative reasons for its rejection in Britain. These included the difficulties of isolating those vaccinated until immunity was ensured at about four weeks, as well as the fact that Britain already had a well-­developed scheme for treating TB with which some commentators believed vaccination would interfere.89 Britain had made a huge investment in hospital treatment, particularly after 1920 when local authorities were required by law 116

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to provide free treatment for all TB patients in their catchment areas. Bryder argues that BCG did not fit into this approach to disease. Furthermore, the majority of British specialists maintained that BCG vaccination would create a false sense of security and that it was better to raise resistance to disease by promoting a change in lifestyles. Johannes Heimbeck raised the question in 1927 of whether nurses could benefit from vaccination. Heimbeck offered BCG vaccination to student nurses employed at Ulleval Hospital, Oslo, who gave a negative reaction to a tuberculin test. Negative-­reacting nurses who refused the vaccine were studied as a control group. The TB morbidity rate amongst this group was six times higher and mortality rate seven times higher than the vaccinated group.90 Scandinavians considered this adequate proof of the value of BCG and vaccination was made compulsory for staff exhibiting a negative reaction in state mental hospitals, the dental service, student nurses and medical students.91 Scandinavia’s different policy to Britain regarding BCG vaccination mirrors ‘the respective social welfare traditions and systems’ according to Bryder. Scandinavia adopted the socialistic policy of treating everyone in the same way, focusing on preventive measures, whereas Britain’s policy up until the Second World War period was founded on a liberal perspective that stressed the freedom and responsibility of the individual.92 An acute shortage of nurses in TB institutions during and immediately after the war prompted the first serious appraisal of the introduction of BCG in Britain.93 In 1949, an estimated shortfall of 2,900 nurses had a drastic impact on the number of available beds.94 Fear of infection, intensified by the publication of surveys showing a high rate of disease amongst nurses, was believed to be inhibiting women from taking up TB nursing. Esther Carling argued that parents were increasingly averse to allow their daughters to nurse in sanatoria. In response to this crisis, tuberculosis specialists asked the Ministry of Health to initiate a study in 1943 and to supply BCG to nurses. However, it was not until 1949 that the vaccination was first offered to nurses as part of post-­Second World War welfare provision. The Prophit Survey The Second World War heightened interest in TB not only because of the shortage of TB nurses but also because of a rise in its incidence. 117

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Fears about the spread of disease were fuelled by disruption to the TB service, particularly when sanatoria were converted to war hospitals and their patients discharged home. Investigation into its extent and causes focused on its incidence, particularly among young women.95 One such investigation was the Prophit Survey, which included five thousand female nurses. Driven by the fact that TB was ‘still the main killing and incapacitating disease’ of young people between the ages of fifteen and twenty-­four, the Royal College of Physicians used a legacy from J. M. G. Prophit, a British merchant, to fund a large-­ scale investigation into the epidemiology of TB. Ten thousand young adults were divided into four occupational groups (nurses, medical students, navy boys, office workers) and a fifth group was made up of contacts drawn from people living in a family with a case of TB. The intention was to observe each group over a period of ten years (1934–44) but nurses became the survey’s focus as the war made it difficult to study the other groups in the same detail. The Prophit Survey concluded that young women were more likely to develop TB than men in similar surroundings. It found that the morbidity rate of general hospital student nurses was four times higher than young women in the general population. This increased morbidity was linked, in 43 per cent of cases, to a recent primary infection and, in 57 per cent of cases, to a combination of genetic, environmental and nutritional factors. Nurses’ resistance to TB, the survey concluded, was the result of a delicate balancing act between these three factors.96 Discussion of risk to disease included social background and work environment. The survey concluded that working-­ class nurses were more vulnerable to illness than their middle-­ ­ class counterparts. Social background was found to play a significant part in the type of hospitals recruits gained entry to and consequently the environmental conditions they experienced at work. Working-­class nurses were more likely to work in hospitals where work conditions had an adverse effect on health. TB rates were higher in these hospitals than in the more prestigious voluntary hospitals that employed a higher percentage of middle-­class recruits and had fewer TB patients. Conclusions about social class were reached by dividing the nurses studied into two groups. Group A nurses were predominately from working-­class backgrounds and worked in long-­stay hospitals that admitted all 118

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types of patients including those suffering from chronic and advanced types of disease. All group A hospitals had TB wards and all had difficulty in attracting new recruits. As part of their training, group A probationer nurses were seconded to TB wards or sanatoria for three months.97 The workload of this group of nurses was noted as heavier than group B’s because they had more patients to care for, many with high levels of dependency.98 Group B contained a higher number of nurses with no previous occupation, suggesting that these women came from families with sufficient income to support them to stay at home and not have to work in the gap between leaving school and starting nursing. Group B hospitals had waiting lists of recruits and were therefore able to apply more rigorous standards of selection choosing ‘the healthiest and best-­educated’. Although The London Hospital was not included in the survey, it was typical of a group B hospital. Only one out of the five group B hospitals had a TB ward and, unlike group A hospitals, open cases of TB were rarely admitted. Group B nurses had fewer patients to care for, with more generous bed spacing between patients.99 The Prophit Survey found that the TB rate amongst group A nurses was consistently higher than B, irrespective of initial tuberculin reaction. The difference was attributed to a greater exposure to TB, lower resistance to disease because of a poor diet and hard work, and a broader social base of nurses in group B hospitals.100 Tuberculin-­ negative entrants were found to be more likely to develop TB during their first year of training, confirming Heimbeck’s conclusions. The incidence of TB amongst nurses who had a positive reaction to the Mantoux test was low in the first year but tended to increase with each year of nursing experience.101 The survey argued that the handling of infected material had been wrongly prioritised as the highest risk procedure, ‘while scant attention is paid to the more serious risks of air-­borne infection (as during bed-­making and ward sweeping)’. It recommended that more importance be attached to hand washing and wearing masks during these high-­risk procedures.102 It endorsed annual weight and X-­ray examinations for nurses under the age of thirty. The Prophit Survey marks a shift in the history of nurses’ occupational health towards the notion that regular standardised health checks throughout the course of employment would reduce the ­probability of disease developing. 119

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A compensable disease As a result of the Prophit Survey and the Dale Committee’s report in 1948, which refined the selection of diseases for insurance under the National Insurance (Industrial Injuries) Act 1946, the Industrial Injuries Advisory Council (IIAC) prescribed TB as an occupational health risk for nurses in 1951. This meant that nurses could claim for compensation if it could be proved that they had contracted TB in the course of their employment. And this, of course, is where the problem lay. The 1946 National Insurance Act ruled that a disease could be prescribed if it could be treated as a risk of occupation and not as a risk common to the general population. TB’s prevalence in the population at large made it difficult to determine, with certainty, the source of infection. The IIAC negotiated this problem by ruling that nurses’ risk of infection came from ‘close and frequent contact’ with patients and with infected materials.103 It was possible to isolate TB as an occupational risk, the IIAC argued, by an initial medical examination on entry to training. The IIAC maintained that, because nurses lived ‘under more hygienic conditions than the general population’, their TB was unlikely to be caused by the factors associated with poor housing. The council also claimed that nurses had a ‘somewhat restricted contact with the outside world’ and this lessened their risk of contracting TB from the general population. This comment is interesting because it constructs an angelic image of the nurse. Indeed the IIAC seem to have made sense of criteria defining occupational disease by thinking of nurses as a type of nun, living apart from society. It suggests that the image of nurses as morally superior, promoted by nurse leaders in the late nineteenth century, continued to influence ideas about nursing well into the twentieth century despite the secularisation of medicine. The IIAC ruled, after lengthy debate, that nurses could claim for compensation six weeks after entry into employment and within two years of leaving. It did not rule out claims being made a number of years after employment had lapsed if it could be proved that TB was contracted during employment.104 First and foremost, it was thought necessary for nurses to establish that ‘close and frequent contact’ with tuberculous infection had occurred. Such contact was considered possible in general hospital wards as well as TB wards and sanatoria. 120

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Indeed, the IIAC considered general nurses to be at particular risk from undiagnosed cases.105 It supported the implementation of BCG vaccination not only to improve nurses’ health but to ‘save the Fund the expense of many avoidable claims’. With this in mind, the Ministry of Health issued a circular that encouraged sanatoria to employ nurses with existing TB infection.106 Their aim was to save the government the expense from paying out a large number of compensation claims. The IIAC debated whether the prescription of TB as a compensable disease might deter potential recruits but decided on balance that it might help recruitment by fostering a sense  of security.107 The Prophit Survey and the IIAC report contributed to a movement demanding that the occupational health of nurses be taken more seriously. A body of opinion now acknowledged that existing systems of care were outdated and improvements would reduce the incidence of TB amongst nurses. Indeed nurses’ risk of TB was at the centre of this drive for reform. For example, in 1939 the Inter-­ departmental Committee on Nursing Services reported widespread failure amongst hospitals to perform even an initial medical examination at the start of training. This, and routine examination during training, was necessary, the committee argued, to allow ‘treatment at an early stage in tuberculosis and other conditions’.108 These recommendations were shelved because of the outbreak of war, and six years later, in 1945, the King Edward’s Hospital Fund lamented the absence of an accepted standard for the supervision of nurses’ health: The requirements regarding the medical examination of student nurses before admission vary widely at different hospitals, the practice with regard to immunisation follows no general rule, and on such questions as routine medical examination and the keeping of health records it must be admitted that other organisations – schools, industrial bodies employing large members of staff, etc. – have been allowed to lead the way.109

The idea that nurses’ health care was falling behind that of other occupational groups gained support. The King Edward’s Hospital Fund pressed the point that ‘recent advances in preventive medicine and staff welfare work’ were cause for hospitals to review ‘the supervision given to the health of the staff’.110 The Fund and the Prophit Survey recommended not only that hospitals take a much more comprehensive approach to occupational health care but that more attention be 121

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given to nurses’ diet and accommodation as a way of building resistance to infection. The problem of TB amongst general hospital nurses was of such urgency, the Fund argued, that it required ‘immediate steps to minimise the risks’.111 No moves were made, however, to enforce hospitals to adopt minimum standards of care. Conclusion The story of the changing risk nurses faced from tuberculosis is an important part of the history of the occupational health of nurses. It was a risk that was for the most part ignored up until the 1930s. This was not because nurse leaders were more concerned with issues of professionalisation, as they had been in the late nineteenth century; it had more to do with the fact that TB did indeed pose little threat to nurses’ health in this early period. Although the statistical surveys of the late nineteenth and early twentieth centuries lacked rigour, it seems that many nurses had built up some form of immunity to a disease widely prevalent in the general population. As its incidence in this wider group declined, so nurses’ vulnerability to TB increased. The issue is further complicated by evidence from my case study institutions that suggests that doctors were reluctant to diagnose nurses with TB until the mid-­1940s. Whether this was because they were keen not to stigmatise staff and reduce their chances of finding alternative work or lose nurses during periods of recruitment difficulties is difficult to gauge. Furthermore, hospitals, wanting to promote a favourable image to counterbalance competition from other occupations, may have been keen to distance themselves from a disease linked to the social and environmental problems of the working classes. But TB is important to the history of nurses’ health also because it became an integral part of the vocabulary used to discuss risk of illness in the 1930s. Indeed at times it was presented as the only health risk nurses faced. This was because of the fluidity of its narrative. It not only was part of the political analysis dissecting the reasons for the recurrent recruitment crises throughout the 1930s but also explained the relationship between nurses’ social class, work and health. Changing cultural perceptions of TB in the general population, that it was no longer considered a hereditary disease of 122

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the middle classes but was now linked to the social and environmental problems of the working classes, framed understandings about nurses’ health. Concern that nursing was no longer attractive to middle-­class women, that the number of working-­class nurses was on the rise and that these women were more vulnerable to TB added gravitas to the issue of nurses’ health. Although more importance was attached to the question of occupational health in the late 1930s and 1940s, particularly when a number of organisations argued that hospitals take a more active role in preventing TB, no attempt was made to encourage the state to regulate any recommendations made. Hospitals remained at liberty to set their own standards of care and this perhaps explains why it was not until the late twentieth century that the majority of nurses had access to occupational health units. Notes 1 G. S. Erwin, Tuberculosis and Chest Diseases for Nurses (London: J. & A. Churchill, 1946), p. 142. 2 BMJ (30 September 1882), 618–19. 3 Consumption was the popular term for the disease but doctors preferred the term ‘phthisis’. Worboys, Spreading Germs, p. 194. 4 King Edward’s Hospital Fund for London, Memorandum on the Supervision of Nurses’ Health for Consideration by Hospitals (London: Geo. Barber & Son Ltd, 1945), p. 7. 5 A. Seidler, A. Nienhaus and R. Dief, ‘Review of epidemiological studies on the occupational risk of tuberculosis in low-­incidence areas’, Respiration, 72 (2005), 431–46. 6 Hawkins, Nursing and Women’s Labour, p. 159. 7 Ibid. 8 S. Kirby, ‘Sputum and the scent of wallflowers: nursing in tuberculosis sanatoria, 1920–1970’, Social History of Medicine, 23:3 (2010), 609. 9 G. Boschma, The Rise of Mental Health Nursing: A History of Psychiatric Care in Dutch Asylums, 1890–1920 (Amsterdam: Amsterdam University Press, 2003). 10 S. Mosley, ‘Fresh air and foul: the role of the open fireplace in ventilating the British home 1837–1910’, Planning Perspectives, 18 (2003), 1–21. 11 L. Bryder, Below the Magic Mountain: A Social History of Tuberculosis in Twentieth Century Britain (Oxford: Oxford University Press, 1988), p. 127. 12 Ibid., pp. 125–7. 13 Ibid., p. 129.

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Who cared for the carers? 14 J. Greenlees, ‘“Stop kissing and steaming!”: tuberculosis and the occupational health movement in Massachusetts and Lancashire, 1870–1918’, Urban History, 32:2 (2005), 223–46. 15 K. Ott, Fevered Lives: Tuberculosis in American Culture since 1870 (Cambridge, MA and London: Harvard University Press, 1996), pp. 1–8. 16 Bryder, Below the Magic Mountain, p. 5. 17 O. V. Buxton and P. M. Maculloch Mackay, The Nursing of Tuberculosis (Bristol: John Wright & Sons Ltd, 1947), p. 10. 18 Rafferty, The Politics of Nursing Knowledge, p. 157. 19 Ibid., p. 141. 20 Ibid.; Abel-­Smith, A History of the Nursing Profession, p. 120. 21 Dingwall et al., An Introduction to the Social History of Nursing, p. 99. 22 Rafferty, The Politics of Nursing Knowledge, p. 148. 23 Abel-­Smith, A History of the Nursing Profession, p. 153. 24 Ibid. 25 Dingwall et al., An Introduction to the Social History of Nursing, p. 101; Rafferty, The Politics of Nursing Knowledge, p. 148. 26 BMJ (30 September 1882), 618–19. 27 Ibid. 28 G. W. Norris and H. R. Landis, Diseases of the Chest (Philadelphia: W. B. Saunders, 1924) quoted in A. Kent and M. D. Sepkowitz, ‘Tuberculosis and the health care worker: a historical perspective’, Annals of Internal Medicine, 120:1 (January 1994), 72. 29 BMJ (21 August 1909), 435–7. 30 Ibid. (30 April 1910), 1039. 31 Ibid. 1040–2. 32 Ibid. 33 J. Heimbeck, ‘Immunity to tuberculosis’, Archives of Internal Medicine, 41 (March 1928), 336–42. 34 Bryder, Below the Magic Mountain, pp. 3–4. 35 J. Heimbeck ‘Tuberculosis in hospital nurses’, Tubercle, 18 (1936), 97–9. 36 Kent and Sepkowitz, ‘Tuberculosis and the health care worker’, 72. 37 D. A. Stewart, ‘The general hospital and tuberculosis patients’, Transactions of the American Hospital Association (1931), 463–6. 38 The BJN acknowledged that the American Journal of Nursing (AJN) contained ‘up-­to-­date matters of interest and instruction for nurses all over the world’ in a note following a report of tuberculosis amongst student nurses which used the AJN as its source. H. Israel, ‘Tuberculosis amongst student nurses’, BJN (March 1942), 52. 39 T. L. Badger and W. W. Spink, ‘Sources of tuberculous infection among nurses’, American Journal of Nursing, 36:11 (1936), 1100. 40 Rafferty, The Politics of Nursing Knowledge, p. 238; ‘Incidence of tuberculosis amongst hospital nurses’, Lancet (19 April 1930), 874–5.

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‘The disease which is most feared’ 41 Lancet (19 April 1930), 874–5; (23 September 1933), 713–14. 42 J. A. Myers, ‘Tuberculosis among nurses’, AJN, 32:11 (11 November 1932), 1159; J. A. Myers, H. S. Diehl, R. E. Boynton and B. Trach, ‘Development of tuberculosis in adult life’, Archive of Internal Medicine, 59 (1937), 1–31; M. Fishberg, ‘Response to recent facts on transmission of tuberculosis’, Journal of the American Medical Association, 97 (1931), 316–19. In 1916 Fishberg published Treatise on Pulmonary Tuberculosis which became a standard text and was reissued in four editions before 1932. For biography see A. Johnson (ed.), Dictionary of American Biography (London: Oxford University Press, 1999). 43 E. Carling, ‘Recruitment for nursing’, Lancet (11 October 1930), 826. 44 McGann et al., A History of the Royal College of Nursing, p. 76. 45 Lancet (11 October 1930), 826. 46 Rafferty, The Politics of Nursing Knowledge, p. 144. 47 Lancet Commission on Nursing, Final Report of the Lancet Commission on Nursing, appointed in December, 1930, to inquire into the reasons for the shortage of candidates, trained and untrained for nursing the sick in general and special hospitals throughout the country, and to offer suggestions for making the service more attractive to women suitable for this necessary work (London: Lancet, 1932), p. xxiv. 48 A. Bradford Hill, ‘Statistical analysis of the questionnaire issued to hospitals by the Lancet Commission on Nursing. Final Report submitted to the Commission by Bradford Hill’, Final Report of the Lancet Commission, pp. i–iii. 49 W. Langdon Brown, ‘The First Stage’, The Times (12 January 1934), 8. 50 Erwin, Tuberculosis and Chest Diseases for Nurses, p. 141. 51 Ibid. 52 BJN (November 1933), 324. 53 A. Bradford Hill, ‘Statistical analysis of the questionnaire issued to Hospitals by “The Lancet” Commission on Nursing. Final Report Submitted to the Commission’, Lancet (15 August 1931). 54 Ibid. 55 Lancet (11 September 1937), 629. 56 The Times (14 September 1936), 8. 57 ‘Nurses’ hours’, The Times (1 February 1936), 8. 58 S. Bevington, Nursing Life and Discipline (London: Lewis, 1943), p. 19. 59 Ibid. 60 Time and Tide, 1945. 61 Erwin, Tuberculosis and Chest Disease for Nurses, p. 142. 62 RLH, LH/A/1/38, General standing orders, 1933. 63 RLH, LH/M/2/78, Medical index of patients, 1930. 64 R. E. Plunkett, ‘Case-­finding, an evaluation of various techniques’, American Review of Tuberculosis, 39:2 (February 1939), 256–65.

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RLH, LH/N/6/53, The London Hospital Official Ward Book, 1930. PWDRO, 1490/27, SDEC Register of Nurses, 1931, p. 8. PWDRO, 1490/27, SDEC Register of Nurses, 1933, p. 16. PWDRO, 606/1/16, SDEC general committee minutes, 23 April 1937. Ibid. PWDRO, 606/1/15, SDEC general committee minutes, March 1929; 22 May 1929. 71 BMJ (13 January 1945). 72 Western Morning News (23 September 1932). 73 PWDRO, 606/1/15, SDEC general committee minutes, 2 November 1931; 29 December 1931. 74 PWDRO, 606/1/30, SDEC nursing committee minutes, 21 October 1932. 75 PWDRO, 1490/25, SDEC Register of Nurses, 1921–25. 76 PWDRO, 606/1/16, SDEC general committee minutes with Prince of Wales house committee minutes, 23 April 1937. 77 Baly, Nursing and Social Change, p. 165. 78 PWDRO, 1490/27, SDEC Register of Nurses, 1929–56. 79 PWDRO, 1490/27, SDEC Register of Nurses, 1929–56; 1941; 1943; 1944. 80 PWDRO, 606/1/17, Prince of Wales Hospital house committee minutes and Joint Meeting of SDEC house committee and medical board minutes, 1943–48, 20 June 1947, p. 173; 14 May 1948. 81 Andrews, The Dark Awakening, p. 201. 82 CRO, HC1/1/1/27, Cornwall Mental Hospital Visiting Committee Minutes (CMHVC) 1931–32, p. 194; p. 196; p. 241. 83 CRO, HC1/1/1/27, CMHVC minutes, 30 May 1932, p. 385. 84 A. Casadevall and M. D. Scharff, ‘Return to the past: the case for antibody based therapies in infectious diseases’, Clinical Infectious Disease, 21 (1995), 150–61. 85 A. Gatman-­Freedman and A. Casadevall, ‘Serum therapy for tuberculosis revisited: reappraisal of the role of antibody-­mediated immunity against mycobacterium tuberculosis’, Clinical Microbiology Reviews, 11:3 (July 1998), 514–32. 86 E. L. Opie and J. Freund, ‘An experimental study of protective inoculation with heat killed tubercle bacilli’, Journal of Experimental Medicine, 66 (December 1937), 761–88. 87 CRO, HC1/1/1/27, CMHVC minutes, 30 May 1932, p. 389. 88 L. Bryder, ‘“We shall not find salvation in inoculation”, BCG vaccination in Scandinavia, Britain and the USA, 1921–1960’, Social Science and Medicine, 49:9 (November 1999), 1157–67. 89 Bryder, Below the Magic Mountain, p. 139. 90 J. Heimbeck, ‘Tuberculosis in hospital nurses’, Tubercle, 18 (1936), 97–9. 91 Bryder, ‘We shall not find salvation in inoculation’, 1160. 92 Ibid.

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‘The disease which is most feared’ 93 Bryder, ‘We shall not find salvation in inoculation’, 1161–2. 94 Ibid. 95 Bryder, Below the Magic Mountain, pp. 229–41. 96 M. Daniels, F. Ridehalgh and V. H. Springett, Tuberculosis in Young Adults  – report of the Prophit Survey 1935–1948 including work done by I. M. Hall (London: H. K. Lewis & Co., 1948), pp. v–viii; 205–13. 97 Ibid., pp. 9–22. 98 Ibid., p. 154. 99 Ibid., pp. 9–22. 100 Ibid., p. 154. 101 Ibid., p. viii. 102 Ibid., p. ix. 103 Industrial Injuries Advisory Council, Report of the Industrial Injuries Advisory Council in Accordance with Section 61 of the National Insurance (Industrial Injuries) Act, 1946, on the Question whether Tuberculosis and Other Communicable Diseases Should Be Prescribed under the Act in Relation to Nurses and Other Health Workers, Cmd. 8093 (November 1950), p. 379. 104 Ibid., pp. 7–12. 105 Ibid. 106 Ibid., pp. 11–14. 107 Ibid. 108 Ministry of Health, Board of Education and Department of Health for Scotland, Interim Report of the Inter-­Departmental Committee on Nursing Services (London: HMSO, 1939). 109 King Edward’s Hospital Fund for London, Memorandum on the Supervision of Nurses’ Health. 110 Ibid. 111 Ibid.

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5

Industrial psychology’s influence on the recruitment and welfare of general and mental nurses, 1930–48 In 1939, Gladys Beaumont Carter, a nurse at King’s College Hospital, London, complained that bullying was common in nursing and that it ‘hindered psychological progress’. It was encouraged by rigid hospital hierarchies, Carter argued, that inflated ward sisters’ and matrons’ power over student nurses: ‘autocracies are suspect, and modern psychologists frank about the motives of matrons and sisters who feel the need to hedge themselves round with forms and ceremonies’.1 Senior nurses’ overriding concern with nurse status, she explained, diverted their attention from the guilt they felt at the poor treatment of their profession.2 Carter was also an economics graduate and author of a number of midwifery textbooks and spoke with some authority when she argued that nurse training failed to address the psychology of the nurse and, as a result, nurses were suffering from mental health problems.3 Psychological ideas about the welfare, selection and training of nurses attracted increasing attention in the period immediately before and after the Second World War. Critics began to identify outdated systems of discipline not only as the reason for mental ill health and low morale but also as the cause of the occupation’s recruitment problems, ignoring the fact that hospital expansion had stimulated a demand for more nurses. This chapter examines the impact of psychology on the organisation of nursing and the health of nurses at the three case study institutions, but, to set this in context, it starts with an overview of the rise of industrial psychology. 128

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Industrial psychology In the interwar years, psychological factors became the basis of a new matrix of relations between management, economic regulation and psychological expertise.4 At its heart was the National Institute of Industrial Psychology, under the direction of Charles Myers (1873–1946). In 1933, Myers, a renowned psychologist and formerly Director of the Cambridge Psychological Laboratory, defined industrial psychology as a science concerned with the application of the ‘knowledge of mental processes to the conditions obtaining in modern industry’. It would deal, he argued, with the human as opposed to the mechanical aspects of occupational life and would not only reduce workers’ ‘effort’ and ‘irritation’ but also increase their interest and contentment in employment. It could be extended to employees from the commercial and professional sectors as well as those from industry, Myers suggested, and would include personality assessment, aptitude testing, vocational guidance, staff selection, work-­study, personnel management and much more. Myers and his colleagues at the National Institute began to recognise that employees were individuals with a particular psychological make-­up in terms of intelligence and emotions, with fears and anxieties, whose work was hampered by worry and boredom and whose efficiency was highly dependent upon sympathy, interest, satisfaction and contentment. They argued that the most effective and productive method of work organisation was not to force employees to work against their will but provide encouragement by removing the difficulties and obstacles that prevented workers from giving their best. The mental atmosphere of the work environment was now considered important and its character linked with management and leadership. Style of leadership was crucial because psychologists believed it could create or destroy the atmosphere of common purpose and morale upon which productivity depends.5 According to Myers, the solution to job satisfaction and increased production was to fit the man to the job and the job to the man. Vocational guidance and selection would help the process of selection through a psychological calculation of suitability.6 Studies in America began to use psychological tools to explain why student nurses became disillusioned during training. Relationships with head nurses and supervisors were identified as an important 129

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determinant of satisfaction. Dissatisfied students were found to be more likely to complain of chronic fatigue but improvements to morale and health could be achieved by making frequent attempts to determine how students felt.7 The selection of recruits during the First and Second World Wars also played an important part in the development of occupational psychology. According to Matthew Thomson, the desperate need for manpower in Britain during the First World War and the deskilled nature of trench warfare made quantity rather than quality of troops the overriding military concern. Circumstances were different in America where the cost of dispatching troops to Europe made authorities more ready to reject the mentally weak. Unlike those in Britain, American recruits underwent psychological testing, with far more recruits rejected for mental or educational reasons. Thompson argues that this led to much lower rates of mental disablement, ill discipline and suicide.8 By the end of the First World War, the inadequacy of British mental testing had become apparent. The Second World War saw extensive use of psychological selection methods with apparently successful results and this impacted on ideas about the recruitment of nurses. At the outset of the conflict, partly in response to the growing technological complexity of warfare, psychologists from the IHRB and other organisations created new psychometric procedures.9 In 1942, the War Office Selection Boards were established, initially for officer selection and later for all army recruits who were subjected to a series of intelligence and aptitude tests and interviews. Sir Robert Wood and John Cohen (authors of two important investigations into nurse recruitment problems in 1947 and 1949) suggested that the Report of the Expert Committee on the Work of Psychologists and Psychiatrists in the Services had influenced their ideas about the selection of nurses.10 The next section traces the rise of psychology in relation to the organisation of nursing by comparing its influence on the final reports of three nursing inquiries in 1932, 1937 and 1947. The Lancet Commission 1932 I have already discussed the Lancet Commission of 1932 in relation to nurses’ TB in Chapter 4 but now I want to examine the ways the 130

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commissioners understood the management of nurses and justified the continuation of a strict system of discipline. This is important because a comparison with later inquiries shows how attitudes to discipline changed over the course of the 1930s and 1940s. The commission, chaired by the Earl of Crawford, represented metropolitan, voluntary hospital and academic interests and included two hospital matrons11 and four doctors,12 alongside Dr Dorothy Brock, President of the Association of Headmistresses and headmistress of the Mary Datchelor Girls’ School, and Miss Edith Thomson, council member of Bedford College. Unlike the later Wood Report the commission did not include a psychologist.13 Given voluntary hospitals’ financial insecurities, the commission’s remit was to make non-­monetary recommendations regarding nurses’ work conditions.14 It aimed to find solutions by adapting existing systems but this restricted remit meant that its report had little impact.15 The extent of the commission’s inquiry was also limited by the size of its sample of nurses. Although it included evidence from the major nursing organisations,16 it received only 686 replies (67 per cent) to the 1,031 questionnaires sent to hospitals in England and Wales.17 Only sixty probationers were questioned directly by interview, selected on the basis that they were ‘personally known’ to commission members ‘or to their friends’. The commission, concerned with nurses’ mental wellbeing and ‘attitude’ to work, attempted to measure nurses’ ‘happiness’. The attitude or morale survey was not just a technique of social research but was also a powerful new device for management. The opinions expressed could be used, as in this case, when recommendations were being formulated or changes made to management policy. It was a way of mapping out the hospital in psychological terms and using the inner feelings of nurses to critique existing policies. Attitudes could be governed in two ways, by communication and by leadership, and it was the latter that interested commissioners. Fifty-­seven of the probationers interviewed declared themselves ‘essentially happy in their profession’ although their evidence in another part of the survey raised more points of objection than support about the system of nurse training. Their objections included ‘excessive restrictions and discipline in the nurses’ home … often treated as children … favouritism and capriciousness among the sisters … nursing obliterated personality’.18 Although the commission dismissed many of 131

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the criticisms as misconceptions, it admitted that discipline needed to be relaxed. Evidence from the 191 mental hospitals suggested that their systems of discipline were more relaxed than voluntary hospitals’. For example, more mental hospitals allowed nurses to smoke and gave more time for meal breaks where attendance was less likely to be compulsory.19 Although the commission supported a relaxation in discipline, it acknowledged that many voluntary hospitals would continue to maintain strict regimes ‘until a better type of candidate presents herself’.20 Commissioners argued that nursing’s failure to attract women of social quality justified the continuation of a disciplined style of nurse management. ‘It is not surprising’, the commission argued, ‘that the hospitals should continue to treat probationers as children, since many of them have not been trained to self-­government before entering hospital.’ Whether the commissioners considered working-­class nurses or the changing pattern of family lifestyles responsible for a lack of self-­discipline among recruits is unclear but they were in no doubt that only after undergoing a ‘firm’ three-­year hospital training was a nurse ‘fit to be trusted to regulate her own life in hospital outside working hours’.21 Although the commission’s stance on discipline appears conservative compared to inquiries even five years later, it was innovative in its willingness to recommend even small improvements to existing regulations. For example, it argued that a trained nurse was capable of caring for herself off duty and that nurses’ homes should be ‘run on informal lines as a hostel under a warden’. It also suggested that probationers should no longer have to go to bed before 10.30 p.m. or put their lights out thirty minutes later.22 ‘Small psychological concessions’, such as going for a summer walk, were recognised as having ‘a psychological value altogether out of proportion to the difference they make in a normal day’s routine’. However, these recommendations failed to tackle the division between some senior nurses, who adhered to traditional nursing values, and younger junior nurses, many of who had received a progressive form of education. This clash of values was identified as the reason why some probationers left nursing. Ideas about the best way to educate schoolchildren changed significantly in the twentieth century. It was no longer considered 132

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appropriate to produce an atmosphere of fear and anxiety in the classroom, according to supporters of the ‘progressive method’ of teaching who advocated that pupils must be allowed to express ‘real character’. A shift in emphasis from external control to self-­discipline as an ideal model for teaching can be traced in successive editions of the Board of Education’s Handbook for Teachers between 1917 and 1937. Teachers were warned not to correct misbehaviour by punishment or repression but to search for its cause in the home or school environment and then help the child to readjust.23 Educational methods now ‘insist[ed] on the importance of developing a student’s personality’ and ‘arousing, instead of dampening, curiosity and initiative’.24 These ideas, which had shaped many nurse recruits’ school education, sat uneasily with the 1930s system of nurse training. Large sections of the nursing profession remained convinced of the value of military-­style discipline that included uncritical obedience, punctuality and loyalty to both their superiors and their training institution. But the occupation faced significant problems in trying to instigate improvements, according to the commission, because some senior nurses felt that because they had endured a strict style of discipline then so should their juniors. Such attitudes were, commissioners argued, responsible for ‘mental conflict’ and ‘worry’ amongst probationers.25 The commissioners left the practicalities of determining appropriate levels of discipline to individual matrons to decide. In reality, this was often done in collaboration with a nursing committee. For example, Gertrude Littleboy, matron at The London Hospital (1931– 38), met with The London Hospital nursing committee to discuss The Lancet Commission on Nursing’s Final Report in June 1932. The committee agreed to make a small concession by allowing nurses forty-­five minutes for dinner instead of thirty and private staff nurses (but not hospital staff nurses or probationers) to keep their bedroom lights on after 10.30 p.m. ‘provided they did not take advantage of the exception’.26 The Lancet Commission produced few tangible results and it was the financial depression of the mid-­1930s that actually resolved recruitment problems.27 Although the commission paid lip service to psychological ideas as reason to change, psychology made little impact on the Lancet’s final report. Stephanie Kirby’s criticism that 133

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it presented less of an accurate situation than a confirmation of the stereotypical views on nursing held by many members of the medical profession is worth noting.28 But this view fails to acknowledge the beginnings of a backlash against traditional discipline. This backlash had little immediate effect, and complaints about nursing’s regimented organisation continued until 1937 when nurses’ frustration with their poor work conditions rose to a head. The Interdepartmental Committee on Nursing Services (Athlone Committee) 1937 In 1937, as a result of economic upturn and high-­profile discontent, nursing came under political scrutiny again as recruitment problems returned. Improvements in medical treatment, as new techniques shortened patient stays, and a further expansion of hospitals and local authority services stimulated demand for nurses.29 Furthermore, the prospect of providing nursing services for military and civilian populations under wartime conditions provided an additional stimulus to government action to resolve the shortage of nurses.30 The government commissioned the Interdepartmental Committee on Nursing Services (Athlone Committee) in 1937 to identify recruitment and training needs in relation to projected demands on health services. In the same year, nurses’ attitudes towards trade union membership began to change. Militant trade union activity erupted, Christopher Hart argues, dwarfing anything that had gone before. Such was the level of protest that the Guild of Nurses, a branch of the National Union of County Officers, organised a march of masked nurses (to avoid victimisation) through central London in protest against poor conditions, calling for a forty-­eight-­hour week and more pay.31 The Interdepartmental Committee, chaired by the Earl of Athlone, King George VI’s brother-­ in-­ law and President of the Queen’s Institute, was made up of twenty members, chosen on the basis of efficiency rather than bringing together a range of interests.32 Its members represented matrons, local authorities, mental officers of health, voluntary hospitals, doctors, the teaching profession, the General Nursing Council, sister tutors and district nursing.33 The four nurses on the committee were all members of the College, and the fact that it took evidence from only sixteen working nurses compared 134

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with thirty-­seven matrons suggests that it reflected senior nurses’ views. Thirty-­seven associations and individuals also gave evidence. National newspapers and journals highlighted nursing’s petty rules and regimentation and linked strict discipline with the hospitals with staff shortages.34 Indeed, newspapers continued to print damning articles on nurses’ work conditions while the inquiry was under way, stirring up tensions between the College and trade unions.35 The Athlone Committee recommended a relaxation in discipline to bring hospitals in line ‘with the best psychological knowledge’, citing the practice of the London County Council, which allowed nurses freedom to leave the hospital in their off-­duty hours and to smoke in their bedrooms.36 Whilst acknowledging the work of the Lancet Commission, the Athlone Committee pointed out that social and cultural change since 1932 had altered women’s attitudes towards discipline.37 The relationship between social change and nurse discipline preoccupied commentators of the time. For example, Evelyn Sharp, a feminist journalist, writing in The Labour Woman, suggested that women’s new position in society was responsible: the change in our ideas as to what young girls and young women may do with their lives is mainly responsible for the reluctance shown by the modern girl to take up nursing … New regard for personal freedom has sprung from the improvement in the whole position of women. Women no longer required supervision in their leisure hours.38

The increasing number of women receiving secondary and higher education and the expanding number of career options meant more attractive alternatives to nursing. Furthermore, the growth of female trade union membership, generally since the First World War, and amongst nurses in the 1930s, may have contributed to the belief that pay and work conditions mattered as much as or even more than the intangible rewards of a vocation. Part of the debate about discipline focused on nurses’ health. For example, the BMA supported a relaxation in discipline, arguing that women in other occupations managed their leisure time without damaging their health.39 Other critics of authoritarian styles of discipline included Harold Balme, a former medical missionary in China and a member of the College of Nursing Council, who blamed matrons’ autocratic power for ‘many of the physical and mental breakdowns which occur among young nurses’.40 135

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In the late 1930s, the turnover of staff in all hospitals was high, partly owing to the demands of training but also because many women left to get married. Wastage figures suggested that a further ten thousand registered nurses were needed to meet existing demand.41 The Athlone Committee saw occupational health care as a solution to the problem of wastage. Nurses’ health was now used as a tool to support and justify organisational change. For example, the age of entry to training was a contentious issue, partly because critics considered younger girls to be more vulnerable to illness. Although the Athlone Report acknowledged that the ‘chronic condition of overwork’ was still a problem for eighteen-­year-­old nurses, most girls, it argued were ‘mentally and physically able to stand the strain of hospital work’ concluding therefore ‘it was reasonable to reduce the age of entry to training’.42 Recruitment problems, the Athlone Report found, had badly affected the supervision of nurses’ health. Many hospitals were so desperate to fill staff vacancies that they failed to medically examine new recruits. Even when candidates were examined at the start of training, the committee found that the majority of hospitals did not carry out routine medical examinations during training. The report recommended that all hospitals medically examine sick nurses who were absent from duty over twenty-­four hours, but this was never implemented. The shortage of nurses also affected the treatment of nurses’ health, encouraging sisters to pass nurses fit for duty with colds, septic conditions and other minor ailments. All nurses were, the committee concluded, ‘enduring a strain which cannot be paralleled in any other profession’.43 Although it clearly deplored the ways nurses continued to suffer as a result of overwork, it interpreted ‘strain’ and physical and mental endurance as an inevitable part of the vocational nature of nursing, supporting the idea that nurses’ hours should remain unregulated. Legislation was ‘impracticable’ and ‘undesirable’, the committee argued, because ‘the nursing of the sick [was] not comparable to a trade or industry where the hours of work can be fixed within reasonable limits’.44 To compete with other types of women’s employment, the Athlone Committee recommended the introduction of a ninety-­six-­hour fortnight to all hospitals but it expected that this would be implemented without compulsion. Unwilling to subsidise or control the affairs of the voluntary 136

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hospital sector, the committee’s discussions regarding nurses’ health failed to instigate any form of regulated occupational health service. The outbreak of war and the appointment of the Earl of Athlone as Governor-­General to the Dominion of Canada provided justification for inaction.45 The interim report was not followed by a final report.46 In August 1939, an Emergency Medical Service was created to prepare the health services to cope with the expected effects of the bombing of civilians. Central government commandeered the public and voluntary hospitals and made finance available to improve equipment and buildings. A Civilian Nursing Reserve was set up and for the first time, following the Rushcliffe Committee, standardised rates of pay were identified for employers to follow. From September 1943, all nurses and midwives were obliged to obtain their employment through an appointments office of the Ministry of Labour and National Service. Despite the improvements in pay (which were no greater in real terms owing to the rising cost of living than nurses had received before the war) the war aggravated the shortage of nurses not only because of the needs of the armed services but also by an increase in the number of hospital beds which opened up new fields of nursing activity.47 The introduction of new drugs and the implementation of regimes of early mobilisation and rehabilitation compounded the situation.48 In March 1945, there were approximately 190,000 nurses, midwives and probationers employed in Britain and about 11,000 vacancies to fill. In September of the same year, the Ministry of Health launched a major recruitment campaign, which aimed to improve the image of nursing.49 Critics argued that the only remedy to the shortage of nurses was to end the exploitation of nurses, which, they claimed, was now affecting patients. The shortage of domestic staff meant that many trained nurses spent a large proportion of their days performing menial tasks.50 In a letter to The Times, Evelyn Pearce, an author of nursing textbooks, and Gladys Carter (mentioned at the beginning of the chapter) accused voluntary hospitals of being dominated ‘by the customs and architecture of 1860’.51 Pearce and Carter represented a new current of opinion in nursing which attacked the matron-­ dominated College of Nursing Council on the grounds that it was out of touch with reality and did not speak for the new generation of nurses.52 137

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The Working Party on Nurse Recruitment and Training 1946 The establishment of the NHS and the anticipated expansion in facilities and increase in demand for labour suggested a comprehensive review of nursing was required. In 1946, the Ministry of Health set up the Working Party on Nurse Recruitment and Training under the chairmanship of Sir Robert Wood. Wood had recently retired from his post as deputy secretary in the Ministry of Education and was now principal of University College, Southampton.53 Other members were Dr Thomas Inch from the Department of Health for Scotland, Dr John Cohen, a psychologist from the Cabinet Office, and two nurses, Elizabeth Cockayne, matron of the Royal Free Hospital, and Daisy Bridges, a public health nurse and former tutor to the Florence Nightingale International Foundation.54 Cohen had worked as a quantitative psychologist at the Psychological Laboratory, University College London. His research interests reflected the eugenic orientation of interwar psychology and, according to Rafferty, ‘its confidence in the application of scientific methods of measurement to the solution of social problems’.55 Nurse organisations were neither consulted about the working party’s composition nor represented on its body. The report’s novelty was in its intention to use a ‘scientific’ approach to the problems confronting nursing, to reach conclusions not based on opinion but ‘verifiable by reference to fact’. Its framework was, to a large extent, ideas developed from the discipline of industrial psychology, particularly ‘the human factor in staff relations. In nursing, as elsewhere, incentives must be kept alive, interests must be sustained, and team-­work must be inspired.’56 As far as psychologists were concerned, this new approach to the organisation of work stressed concern for the positive mental health of the employee alongside a view of organisations as a network of attitudes, meanings and values.57 Work simplification, as the Wood Report explained, was also important because of the time and effort saved and the ­consequent reduction in fatigue.58 Drawing on research methods common in education and operational research, the Wood Report’s innovative method involved psychometric testing, job analyses and surveys of the causes of student wastage, nurses’ ability and selection procedures. Cohen believed the answer to nursing’s problems was to be found not in repeated 138

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committees but in scientific research and placing conclusions and solutions in the context of wider health service developments. One of the report’s goals was to cut nurse wastage.59 Again, authoritarian styles of discipline were identified as one of its main causes and the report included comments from former student nurses to illustrate its negative effects. Complaints focused on the lack of help many students felt they had received from senior staff who they alleged begrudged them better training and greater freedom. Discipline was no longer to be used to reinforce status and etiquette, the Wood Report asserted, but was to be replaced with a meritocratic system that recognised experience and ability. To achieve this, it recommended a radical reorganisation of the selection of nurses, arguing that it was no longer acceptable that only matrons decided on candidates’ suitability. Many matrons, the report alleged, were ‘unfitted on grounds of personality’ to manage students and staff and perpetuated a narrow, authoritarian regime by selecting staff with similar attitudes from their own hospitals, a system that caused low morale and ‘psychological damage’ to junior staff.60 The report instead recommended the introduction of staff selection boards, modelled on the War Office Selection Boards, and specified that boards include a qualified psychologist and psychometric testing. The selection of senior nurses was now to include a biographical and personal questionnaire (a psychiatric ‘screening’ device for detecting unsuitable individuals) and verbal and non-­verbal intelligence tests; group discussions; test of teaching skills and written views of questions of nursing life and discipline.61 Student nurses were to be selected on the basis of an interview by a personnel selection officer, a questionnaire analysing occupational preferences and health and standardised intelligence testing.62 Intelligence tests were seen as the solution to wastage problems because of their apparent capacity to discriminate between innate talent and social background.63 However, such tests were not impartial and favoured the educated.64 The report’s aim was to reform selection along similar lines to the armed forces but, as will be shown later in this chapter, some senior nurses including matron Claire Alexander of The London Hospital, were determined to resist this challenge to their authority. Nurses’ sickness was another common cause of wastage, according 139

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to the statistics submitted, and rates were significantly higher among female voluntary hospital probationers (18 per cent) than among male (5 per cent) and female (8 per cent) mental hospital nurses. Although the supervision of nurses’ health had received more attention in the 1940s, the report suggested that the high sickness rates were caused by ‘the strains … the profession imposes on her – ­relatively long hours of work, comparatively little recreation and almost constant exposure to infection of one kind or another’.65 Like other reports of the time, it recommended regular health checks and active encouragement of the reportaging of minor illnesses. The Wood Report was not without controversy; dissension split it into two uneven camps, leading to the production of majority and minority reports. Cohen refused to sign the Wood Report, objecting to its focus on material recommendations. His divergence was also partly political, implying that the Wood Report had toned down its representation of the negative aspects of nursing conditions. Cohen prepared a Minority Report with assistance from Geoffrey Pyke, a journalist and educationalist. By 1947, several commentators including the Wood Report and Cohen’s Minority Report had recommended sexual equality in nursing.66 ‘Experience in the Services’ during the Second World War had ‘shown that there [was] no valid reason for sex distinctions’. ‘Suitable personality’ and ‘necessary qualifications’ were now recommended as the deciding factors regarding the employability of a nurse rather than gender.67 Drawing on research studies studying the relationship between sex difference and occupation as criteria in determining occupational suitability,68 the Wood Report argued that the best nurses combined both masculine and feminine qualities. It recommended that a scale for assessing masculinity and femininity, developed by American psychologist Lewis Terman in 1936, be adapted for assessing student nurses.69 Domesticity, considered a qualification to nurse in the late nineteenth century, was not a desirable quality in 1947. According to Terman, domestics stood at the feminine and opposite end of the personality scale to practising nurses. This, the Wood Report explained, was the reason why ‘the attempt to burden student nurses with nursing and domestic tasks calling, apparently, for diametrically opposed qualities, breaks down in the form of wastage during 140

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training’.70 The shortage of domestics and the fact that many hospitals had been unable to afford to replace worn-­out vacuum cleaners and electric floor polishers during the war, forcing nurses into hard manual work,71 meant that the issue of menial cleaning as a nursing task was as topical in the mid-­twentieth century as it had been in the late nineteenth. The number of male nurses had increased dramatically from 3.9 million in 1931 to 17 million in 1946, largely as a result of the war.72 The employment of large numbers of men as nursing orderlies in the services had stimulated interest in civilian nursing as a suitable male occupation both in hospitals and in the public health field.73 As a strategy to overcome the nursing shortage, men’s role in the NHS attracted increasing attention. Reflecting the anxiety over men’s integration into the hospital system, the Wood Report suggested that men could ‘fill the gaps … in the scarcity fields’ of TB nursing and the care of the chronic sick, ‘the type of “heavy case” requiring great physical strength as well as nursing skill’.74 By promoting the notion that physical strength qualified men for certain roles, it encouraged them to work in the more unpopular areas of nursing, suffering acute shortages and away from the prestigious posts in voluntary hospitals. Cohen took exception to this approach, envisaging a much wider role for the male nurse. Prejudice against men in nursing was rife, according to Cohen, because some doctors, nurses and administrators believed that the scope of male nurses was limited and feared that the reaction of female patients would be unfavourable.75 Although the Wood Report was well received by the Ministry of Health, nurse leaders were shocked by its findings and rejected its recommendations. The College of Nursing would not officially endorse the report. Whilst the Wood Report antagonised the nursing profession, Cohen’s minority report provoked anger.76 Although the initial drafting of The Nurses’ Act of 1949 was based on the Wood Report’s recommendations, by the time it reached the statute books there was very little evidence of this fact. In the context of this chapter, both reports suggest that psychological ideas underpinned postwar inquiries about the organisation of nursing. The next section will examine how these inquiries impacted on nursing in the three case study hospitals. 141

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South Devon and East Cornwall Hospital The SDEC underwent significant change in the 1930s. An extension was completed in 1930, and in 1934 the hospital amalgamated with the Royal Albert Hospital and the Central Hospital, becoming the Prince of Wales Hospital.77 Each hospital retained its own matron, who attended a monthly joint nursing committee. Chaired by Dr Lindsay, its membership included more doctors than nurses. In 1931, C. K. Lees, a nurse and midwife, was appointed matron of the SDEC and remained in post until 1937. Lees had trained at the Western Infirmary, Glasgow, and had been matron at St Mary’s Hospital for Women and Children in Manchester. Discipline on and off duty was important to Lees and shaped her style of management. For example, in 1933, she dismissed Lillian C. for fraternising with the son of a hospital cleaner.78 Probationer nurses were unhappy with their work conditions and, in 1932, a group of twelve wrote a letter of complaint to the local newspaper, the Western Morning News. The letter damaged the hospital’s reputation, according to Lees, and she sacked the group’s ringleader, probationer Van Unsworth, noting that she was a ‘smart girl, ward work good but had no regard for hospital discipline’.79 The remaining eleven nurses involved were asked to apologise or leave: all chose to apologise. What is interesting about this incident is that Lees’s style of management received no criticism from the Board of Governors and she continued to reinforce her authority until 1937 when she resigned. Although the hospital experienced a shortage of recruits in 1931, 1932, 1936 and 1937, Lees did not consider relaxing discipline to attract more staff. The SDEC and the other hospitals in the Prince of Wales group were situated in the centre of Plymouth, an area that suffered considerable damage during the Blitz. Both the SDEC and the Royal Albert Hospital were bombed in January 1941 and, although there were no deaths, two nurses were injured in the raid.80 The war exacerbated the hospitals’ recruitment problems and, in 1943, the Prince of Wales Hospital was short of two trained nurses and five probationers. As a move to attract new recruits, matron Kenwell relaxed discipline by letting student nurses attend lectures out of uniform and, although the change in policy was publicised in local newspapers, it had little effect and the shortage continued. 142

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The war impacted badly on nurses’ work conditions and, in 1942, a group of trained nurses and probationers complained to a local newspaper, the Evening Herald, of long working hours, a lack of lectures, poor diet and too much domestic work: We have been told that we belong to a noble profession and that we are doing a great bit in the war effort. Are we supposed to be so noble that we require neither salary nor respectable food to carry on our work? … This is written by a group of nurses who are utterly worn out, overworked, underfed, underpaid.81

Monica O., the letter’s principal author, claimed to have had only four lectures between April 1941 and August 1942, and (perhaps unsurprisingly) none during the Blitz!82 She also resented working sixty-­ three hours a week and even alleged that the doctors and Kenwell received better food than the nurses.83 The Athlone Committee noted in 1939 that it was no longer possible to rely on a sense of vocation as a stimulus to nurse but the tone of these nurses’ letter suggests that they had reached breaking point as far as their ability to sustain the physical hardship of nursing was concerned. For them, neither a sense of vocation nor the notion of contributing to the war effort was compensation for their poor work conditions. In contrast to the Board of Governors’ uncritical support of Lees’s disciplinary approach in 1932, the joint nursing committee interpreted the letter of complaint as an indication of Kenwell’s unfair attitude towards her nursing staff. The fact that the nurses had resorted to the press to air their grievances was taken as a measure of Kenwell’s failure. Although Kenwell had suspended the principal author of the letter, Monica O., the nursing committee overrode this decision and chose to reinstate her. It was not the nurses’ breach of discipline that came under scrutiny but Kenwell’s ability to perform her job. Criticism from the nursing committee identified Kenwell’s ill-­ health and ‘lackadaisical’ attitude as the cause of her inefficiency and suggested that she lacked the fibre for her job. Her frequent absences from work because of ‘sickness, accident and other causes’ were no excuse, the nursing committee argued, unsympathetic to the notion that Kenwell’s failure to manage the nurses successfully might be the result of her own ill-­health. The nursing committee reiterated their high expectations of the matron’s role, that she ‘should be competent and thoroughly familiar with all the detailed routine of the hospital, 143

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must be so observant and comprehending that she is able to visualise what is going on, not only in her presence but in her absence’. Clearly Kenwell was struggling to meet these high standards. The idea that matrons were to blame for the recruitment problems, espoused by the Wood Report, created an image of gorgons. Kenwell was undoubtedly a strict disciplinarian but she was also trying to manage a hospital that was always ‘on take’ to emergency admissions, with a reduced number of nursing staff, as well as coping with her own health and personal problems during a war. The joint nursing committee, like the Wood Report, felt that ordinary nurses ‘had cause for complaint’ in the 1940s. At the Prince of Wales Hospital, working conditions had reached a deplorable standard, according to the committee, who highlighted too few lectures, the poor quality of food and long hours of duty. These were problems, the committee argued, that could have been ‘easily removed by any comprehending, understanding and efficient matron’. The chairman of the committee, Dr T. Pierson, suggested that the absence of Mr Pine, a hospital administrator, who ‘handled complaints tactfully and immediately they came to knowledge’, had contributed to the unrest. The idea that the management of nurses should now include prompt response to complaints and an awareness of nurses’ feelings reflected similar views to that discussed in the Wood Report. The committee realised that if nurses were treated with respect then they were more likely to tolerate the difficulties of the war. It decided not to dismiss Kenwell because of the detrimental effect this would have on the hospital’s reputation but to put her on three-­month probation, a restriction that failed to prevent Kenwell reasserting her authority three months later when she dismissed Monica O. for breaching the 10 p.m. curfew on more than three occasions.84 A survey of the SDEC’s nursing staff by the Ministry of Labour and National Service, in November 1945, acted as an incentive to improve nurses’ quality of life and reduce levels of discipline. For example, nurses were now allowed to smoke in their bedrooms and sitting rooms and have their own telephone.85 The fact that relaxing discipline cost nothing made it the preferred option to attract recruits in times of economic hardship. In response to further recruitment problems, trained nurses were allowed to live out and those living in received free bath towels and a table tennis table. Two years later, 144

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again in response to recruitment problems, nurses were issued with keys to their bedrooms.86 This case study suggests that the ways nurses were managed in the Prince of Wales Hospitals changed significantly between 1932 and 1945. These changes followed a similar trajectory to that seen in national ideas about the organisation of nursing. For the first time, the balance of power was shifting towards the student nurse to the extent that matrons began to be called to account for their attitude to discipline and their disregard for nurses’ welfare. As we will see, this was not the case at The London Hospital. The London Hospital The London Hospital was the largest voluntary hospital in England in the 1930s with approximately 750 sisters, nurses and probationers caring for 850 patients.87 It struggled financially in the interwar period because of the demands placed upon it by new techniques and medical developments, together with the additional patients that these brought.88 There was no shortage of trained staff as the hospital still employed two hundred private staff nurses, who, in emergencies, were drafted on to the wards. Neither was there a shortage of domestic staff, with two ward maids attached to each ward.89 As at the SDEC, discipline was strict both on and off duty. Matron Gertrude May Littleboy (1931–38) trained at The London Hospital and worked there as staff nurse, sister, assistant matron and matron. She was also vice-­president of the National Council of Nurses of Great Britain.90 As mentioned earlier, Littleboy and the nursing committee did make a small concession to the Lancet Commission but many aspects of the nursing day remained unchanged from Luckes’s era. For example, attendance at meals was compulsory and even ward sisters were marked in for breakfast and a late list was put up in matron’s office. Great importance continued to be given to a nurse’s ability to obey commands but, like the Lancet Commissioners, Littleboy considered that middle-­class nurses were easier to train. When an undisciplined nurse challenged this belief, she responded by either dismissing the nurse in question or encouraging them to resign. For example, Littleboy noted that ‘from the beginning Betty W. was not 145

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an easy probationer to train, despite being educated and intelligent’. This was because, Littleboy suggested, her family had let her do as she wanted and, as a result, ‘she found it difficult to conform to discipline’. Littleboy disciplined her twice about her untidy room and later Betty resigned because of the restrictions off duty.91 Littleboy was evidently disappointed that Betty failed to live up to the expectations she associated with an educated middle-­class background. The Lancet Commissioners also equated social background with self-­discipline and argued that the lack of middle-­class recruits in the 1930s justified a continuation of authoritarian styles of management. But Betty’s case suggests that the relationship between social class and self-­discipline was more complicated than the commissioners perceived. Nurses’ illness remained a sensitive issue at The London Hospital. It continued to be surrounded by suspicion and was sometimes interpreted as a lack of self-­discipline. Ivy E., aged twenty-­three, was dismissed because, according to Littleboy, ‘she was rather lazy, very feeble about her health and went off duty for the slightest ailment’. Despite a catalogue of illnesses including removal of ganglion, tonsillectomy and gastric symptoms that involved vomiting blood, Littleboy suggested that ‘Ivy E. tampered with the thermometer and exaggerated her symptoms all she could’.92 Littleboy had been Luckes’s assistant matron and was, like Luckes, suspicious about nurses’ illness. Littleboy retired in 1938 and, in 1939, following the recommendation of the Athlone Report, nurses’ working hours at The London Hospital were changed to a ninety-­six-­hour fortnight. To accommodate this change, the nursing subcommittee decided that a hundred new nurses were needed. A successful recruitment campaign meant that, unlike the Prince of Wales Hospital or the Cornwall Mental Hospital, The London Hospital did not experience acute recruitment problems during the war. Attitudes towards discipline became more relaxed under the leadership of Clare Alexander (1941–51). Alexander trained at The London Hospital and in 1935 became its first qualified sister tutor. She was matron at Addenbrooke’s Hospital, Cambridge, from 1938 to 1941. A national leader, she was vice-­president of the National Council of Nurses of Great Britain and Northern Ireland, vice-­chairman of the 146

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GNC and the only registered nurse-­member of the Central Health Services Council.93 Keen to establish a personal relationship with her staff, she encouraged nurses to confide in her by increasing the ‘at home’ session on Tuesday nights, favoured by her predecessors, to twice daily clinics. In 1945, she ‘hoped that every member of the nursing staff [would] always feel that she [could] come to her personally for help and advice on any matter’. This presents a softer image of the matron than that portrayed by the Wood Report but her advice was often underpinned by the traditional ideology of dedication to duty albeit delivered in gentle language. For example, she told student nurse Hazel R., who ‘felt very tired, nervy to try and make a little more effort and to go to the nurses’ sick room for a tonic.94 Alexander was at least sympathetic to nurses’ problems and many nurses held her in such a high degree of affection that they often returned to visit after leaving. Despite the fact that there were no recruitment problems at The London Hospital, some off-­duty rules were relaxed in 1945. For example, nurses were allowed to smoke in their bedrooms and were given two midnight passes per month in addition to an 11 p.m. pass each week. The change in rules in the student nurses’ home prompted complaints from trained staff about an increase in the level of noise. In response, Alexander reintroduced a stricter regime of rules, which included banning the use of electric driers in the shampoo rooms after 10 p.m. She also forbade nurses to play mixed tennis doubles with the medical students except during the annual tournament.95 The new regime prompted several student nurses to write to The Daily Express threatening to go on strike.96 Aggrieved at the early-­to-­bed rules and ‘non-­fraternisation with the medical students regulations’, the student nurses asked ‘how many other women doing responsible work would want to switch off their radio programme at 11 every night?’97 The threat of strike action suggests that the notion of self-­sacrifice had lost its influence over general nurses’ behaviour. Although Alexander was a liberal reformer in many ways, student nurses felt that the regulation of relationships was out of date. Alexander took the fact that the hospital was in ‘loco parentis’ to young women seriously, a fact disputed by the student nurses who pointed out that the majority of student nurses were ‘in the middle twenties’.98 147

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Alexander’s response to the publication of the Daily Express letter is noteworthy. Unlike Lees of the SDEC, Alexander did not sack the letter’s principal authors nor did the nursing committee interpret the letter as evidence of her inefficiency, as the Prince of Wales Hospital nursing committee had done. Instead, Alexander chose to do nothing on the understanding that ‘anything they wrote to the press would be distorted and utterly misrepresented so that no useful purpose would be served’.99 This pragmatic response conveys Alexander’s confidence in her ability to manage the nursing department successfully at a difficult time, safe in the knowledge that she had a waiting list of recruits and the support of the medical staff. It is difficult to unpick the factors that prompted Alexander’s relaxation in discipline. Because it was not a response to recruitment problems, one might deduce that, as a national leader, she was influenced by the culture of psychology that shaped the Wood Report. However, Alexander showed on two occasions that she was determined to resist the influence of psychological expertise and use psychology to further her aims. Following the Wood Report’s radical proposals to change the system of recruiting probationers, the Ministry of Health approached a number of London hospitals to trial-­run new selection procedures. Alexander was asked if interviewers, trained by the National Institute of Industrial Psychology, could interview candidates in addition to their interview with her and the sister tutors. Alexander was willing to co-­operate but reassured the nursing committee that the status quo of the hospital would be maintained and ‘there was no suggestion that the Interviewers were going to try and influence her in the selection of candidate’.100 She had no intention of relinquishing her authority to psychologists and the committee supported her. The second occasion of Alexander’s resistance to psychological expertise followed psychologist Dr Sheila Bevington’s recommendation that matrons should appoint welfare supervisors to be responsible for nurses’ ‘cultural and social development’ as well as their physical wellbeing. Bevington’s influential book Nursing Life and Discipline, cited by the Wood Report, suggested that welfare supervisors could assist matrons with recruitment and ‘the humanisation of staff relations’.101 Alexander took exception to this idea on the grounds that she did not want ‘a Welfare Officer acting 148

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as a go-­between between her and the nursing staff.’ Instead she appointed a ‘social secretary to assist with the various activities she (the Matron) felt were desirable for the Nursing Staff’. Alexander appointed a ‘lady’ herself, paid her salary from her own ‘special’ fund and limited the role to arranging ‘educational and social visits’ and booking entertainment and travel tickets.102 Thus, she effectively eliminated any threat to her authority but, on the other hand, also kept opportunities to get to know her staff to the maximum. In contrast to the image of matrons created by the Wood Report, Alexander perceived staff relationships to be an important element of the matron’s job to the extent that she was willing to ensure nurses enjoyed their social lives but doing the activities that she felt suitable. Alexander’s attitude to male nurses illustrates how prejudice against male nurses manifested itself in the immediate post war period despite the Ministry of Health’s moves to encourage men into general nursing. Despite the fact that the term ‘attendant’ was dropped in 1919 and replaced by ‘nurse’ as part of the National Programme adopted by the NAWU,103 Alexander continued to refer to male nurses as attendants. This term may have carried the negative connotations associated with male asylum attendants in the late nineteenth century who, as discussed in Chapter 2, had little training. Female probationers at The London Hospital were now referred to as student nurses. The contrast in status between the terms ‘attendant’ and ‘student nurse’ emphasised a distinct boundary between male and female groups. Alexander was determined to prevent men getting a foothold in nursing at The London Hospital. Fearing that male attendants would encroach on the work of female nurses and medical students, she introduced a new set of rules in June 1948 ‘to curtail’ male nurses’ ‘nursing activities’, acknowledging, that the rules would ‘discourage certain men with ambition from continuing this work’. By October 1948 all but one of the male nurses had left and medical students were allocated their duties. The remaining attendant, Mr Adams, resigned in July 1950 because ‘he found the work too much for him’.104 The restrictions surrounding male nurses at The London Hospital did not encourage a career in nursing. In summary, discipline was significantly relaxed at The London 149

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Hospital in the 1940s even though it was not experiencing recruitment problems. Alexander’s style of leadership was very different to her predecessors, because she saw the nurse as much more than a replaceable commodity. Concern for the welfare of nurses prompted the development of a personal counselling service and the appointment of a social secretary. Many of her ideas were similar to those promoted by the National Institute of Industrial Psychology, who recognised that employees were individuals with particular psychological make-­up in terms of emotions, and whose efficiency was highly dependent on sympathy and interest. The Cornwall Mental Hospital The management of the CMH was reorganised in 1928 when the hospital became the property of Cornwall County Council. The new visiting committee, in accordance with the Lunacy Act of 1890, had fifteen members, ten of who were appointed by Cornwall County Council; the remaining five represented the subscribers. In 1930, and following the Mental Treatment Act, which introduced the notion of voluntary treatment for the mentally ill, the committee insisted that the institution be referred to as a mental hospital and not as an asylum. Like the general hospitals studied, the CMH expanded its facilities and treatments in the interwar period. In 1939, for example, a pathological service was set up to tackle the problem of infection.105 Not only did the introduction of drug therapy revolutionise psychiatric care but nurses began to focus on treating patients’ mental health by teaching new skills. Occupational therapy was introduced in 1927 when an attendant began instructing patients in mat-­making and basketwork. Control by the County Council made some difference to the management of nurses. Charge nurse H. G. Woods described how as old administrators left ‘we were controlled by younger and more enlightened personnel’ and, as a result, ‘the quality and service of food improved’.106 The nursing department was modernised in 1926 following a circular from the Board of Control that recommended senior nurses should be registered in both general and mental nursing and that separate nurses’ homes should be provided for staff.107 The 150

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hospital was approved as a training school for mental nurses in 1924 and, initially, staff felt that there was not enough financial incentive given to passing the exam. In June 1933, in reply to an enquiry from the General Nursing Council as to why there were no applications for entry between 1926 and 1932, the visiting committee maintained that the Medico-­Psychological Association examination was useful only to the nurse staying on in service.108 The exam, according to the committee, appealed more to male attendants than the female nursing staff because men regarded the job of mental nursing as their life’s work while most of the female staff regarded it as temporary ­employment pending marriage.109 Discipline remained strict and continued to be regulated by medical superintendent Dr William Gregory Rivers (1931–39). For example, nurses were charged if they lost the hospital’s keys.110 Rivers policed staff relationships, which the Athlone Committee noted to be a problem in mental hospitals in this period because girls’ sole interest was ‘masculine friendships’ and not education and training and this was thought to be deterring more suitable candidates. It is difficult to know whether the ultimatum given to attendant Garnett T. either to lose three years’ service or to face dismissal unless he married pregnant nurse Hannah F. within one month arose because Garnett had broken hospital rules or because Rivers was determined to instil a code of morality.111 CMH nurses’ lives differed significantly during the Second World War from the First World War, when nurses’ health suffered badly from infectious diseases caused by overcrowding and poor diet. At least 80 per cent of the nursing staff now lived out. Indeed, nurses’ health was not discussed at any committee meetings throughout the war. The hospital did experience recruitment problems though. In 1942, there were only fifty-­five full-­time and thirteen part-­time female nurses out of a complement of ninety-­ nine. Despite the Minister of Health’s ‘standstill order’ of 1941, which ruled that any person employed as a nurse in a mental hospital must continue their service until his or her services were no longer required, nine nurses left in 1941 and 1942, of whom eight had under one year’s service. As a result, all nurses had to do overtime and two ward maids did nursing duties. Medical superintendent Stanley Coleman considered the hospital’s isolated position to be the main cause of its recruitment 151

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problems and so provided a car to take nurses home to local villages each evening and also on alternate Sundays. Coleman became increasingly concerned with improving morale as a way of reducing the high wastage rate. Staff dances were held regularly and a badminton club resurrected. These pragmatic changes had little effect and, by 1943, the number of female nurses had dropped to fifty. Desperate for staff, the hospital recruited nurses from the Labour Exchange but these were often considered unsuitable: for example, temporary nurse W. H. Ford ‘entered the service on March 8th and was discharged on March 17th on account of unsuitability’.112 Such short periods of service suggest that the hospital’s regime may have been too difficult even for suitable nurses. In 1946, a nurse on duty was expected to be ‘in charge of fifty to sixty difficult cases’.113 According to ward sister Eileen Goff, ‘the nights were very frightening to a lot of nurses owing to blackout … Many nervous girls didn’t last their period of night duty but left with perhaps half of it done.’114 As the number of nurses fell, nurses at the local emergency hospital were asked to volunteer. In a bid to attract recruits, Coleman extended the staff social programme again to include membership of the local library, a series of general interest talks and social evenings. In 1944 and 1945 Coleman wrote unsuccessfully to Ernest Bevin, Minister of Labour, to ask for more nurses. But although Coleman was desperate for staff, he maintained strict standards of discipline at work. For example nurse Elsie R. was dismissed for taking a day off work without permission and charge nurse William C., found asleep on duty in charge of suicidal and other special patients, was downgraded to staff nurse despite appeals from his trade union.115 In summary, discipline on duty at the CMH remained strict throughout the 1930s. Acute staff shortages during the Second World War and the appointment of a new medical superintendent prompted a relaxation in off-­duty discipline, similar in character to that in the two voluntary hospitals studied. Staff morale began to attract importance but Coleman’s ideas were also shaped by his desire to control the ways his staff spent their leisure time. He did not reference industrial psychology as a management framework but his ideas were similar to some of those put forward by the Wood Report. 152

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Conclusion Industrial psychology underpinned national ideas about the organisation of nursing in the mid-­1940s. The notion that the mental atmosphere of the hospital depended on management and leadership, that each nurse’s wellbeing was important and that staffing problems could be resolved by improving the selection of nurses were ideas rooted in interwar industrial psychology. The nurse was no longer to be degraded to a servile mechanism of management, according to psychologists, but treated as someone with a complex subjective life that needed to be understood if nursing was to take account of the human factor and reduce its problem of wastage. The idea that contentment was to be understood in terms of nurses’ ‘attitude’ to their work prompted interest in nurses’ feelings. But as a result, rather than taking multi-­factorial causes of the recruitment problems into consideration, inquiries explained nursing’s problems by creating an image of modern girls constrained by outdated regimes of discipline imposed by gorgons of matrons.116 A culture of blame was unfairly directed at matrons who, these case studies suggest, were attempting to relax discipline and improve morale at the same time as fulfilling what they perceived to be their care of duty to young women in the difficult circumstances of war. Local hospital policy regarding discipline and morale followed a similar trajectory to national ideas. Interest in nurses’ mental welfare at the case study hospitals was driven by recruitment issues caused by hospital expansion, advances in medical treatment, changes to nurses’ hours and, most importantly, the need to attract and retain staff during the war. There was a shift from the authoritarian regimes of the 1930s, when the voluntary hospital matrons managed with considerable power, to a more relaxed approach to off-­duty discipline in the 1940s. At the Prince of Wales Hospitals, doctors, like the Lancet Commissioners, allowed the matron to govern as she saw fit in 1932 but by 1945 they tried to rein in her power. CMH matrons continued to have little power over discipline despite the fact that they were now qualified in mental and general nursing. However, the medical superintendent’s style of management was similar to that practised by the matron at the SDEC where on-­duty rules remained strict but off-­ duty regulations were relaxed. Although national inquiries justified 153

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proposals for change on the grounds of nurses’ mental health, and Alexander’s counselling service aimed to alleviate anxiety, the two provincial hospitals did not validate change with reference to health. In contrast to the First World War, there is no evidence that nurses’ occupational health deteriorated at the case study hospitals during the war despite the fact that nurses complained of overwork and poor diet. Although evidence from the national inquiries highlighted sickness as an important cause of wastage and recommended the introduction of regular medical checks to screen for TB, nurses’ physical health was not a priority at the case study institutions which were more concerned with mental welfare by providing a less constrained living environment with stimulating activities. Notes 1 G. B. Carter, A New Deal for Nurses (London: Victor Gollancz Ltd., 1939), pp. 141–74. 2 Ibid. 3 Ibid., pp. 136–53; G. B. Carter, The Midwife’s Dictionary and Encylopaedia (London: Faber and Faber, 1939); G. B. Carter, G. H. Dodds and P. J. Cunningham, A Dictionary of Midwifery and Public Health (London: Faber and Faber, 1963). 4 N. Rose, Governing the Soul: The Shaping of the Private Self (London: Free Association Books, 2nd edn, 1999), p. 66. 5 Ibid., p. 87. 6 Ibid., p. 68. 7 Editorial, ‘The general staff nurse. A study of the general staff nurse in eighteen states’, AJN, 38 (1938), 1221–7; Bureau of Labor Statistics, US Department of Labor, ‘The economic status of the nursing profession’, AJN, 47 (1947), 456–62; H. Nahm, ‘Factors associated with job satisfaction in nursing’, AJN, 40 (1940), 1389–92. 8 M. Thomson, ‘Status, manpower and mental fitness: mental deficiency in the First World War’ in R. Cooter, M. Harrison and S. Sturdy (eds), War, Medicine and Modernity (Stroud: Sutton Publishing Ltd, 1998), pp. 151–9. 9 L. Koppes (ed.), Historical Perspectives in Industrial and Organisational Psychology (London: Lawrence Erlbaum Associates, 2007), p. 99. 10 W. Jameson, Report of an Expert Committee on the Work of Psychologists and Psychiatrists in the Services (London: HMSO, 1947). 11 L. Clark, Matron, Whipps Cross Hospital; R. Darbyshire, Matron, University College Hospital. 12 Henry Clay, late Professor of Social Economics, University of Manchester;

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Industrial psychology’s influence F. R. Fraser, Professor of Medicine, University of London; Dr Robert Hutchinson, Physician, The London Hospital and the Hospital for Sick Children, Great Ormond Street. 13 Other members included A. Lister-­Harrison, Chairman, Committee of Management, Metropolitan Hospital; Mrs Oliver Strachey, Chairman, Employment Committee, London, and National Society for Women’s Service; Miss E. Thompson, Member of Council, Bedford College, University of London; Sir Squire Sprigge, Editor of Lancet; Lancet Commission on Nursing, Final Report, p. 7 14 Dingwall et al., An Introduction to the Social History of Nursing, p. 99. 15 Lancet Commission on Nursing, Final Report, p. 11. 16 Catholic Nurses Guild; The College of Nursing; Association of Hospital Matrons; International Council of Nurses; Mental Hospital Matrons Association; Queen Alexandra’s Imperial Military Nursing Service; Queen Alexandra’s Royal Naval Nursing Service; Queen’s Institute of District Nursing. 17 Bradford Hill, ‘Statistical analysis of the questionnaire’, p. II. 18 Lancet Commission on Nursing, Final Report, pp. 178–9. 19 Bradford Hill, ‘Statistical analysis of the questionnaire’. 20 Lancet Commission on Nursing, Final Report, pp. 28–31. 21 Ibid., p. 32. 22 Ibid., p. 170. 23 Bevington, Nursing Life and Discipline, pp. 62–5. 24 Lancet Commission on Nursing, Final Report, p. 29. 25 Ibid. 26 RLH, LH/A/9/63, The London Hospital nursing committee minutes, 27 June 1932, p. 37. 27 S. Kirby, ‘Recruitment, retention and representation of nurses: an historical perspective’, Journal of Clinical Nursing, 18 (2009), 2725–31. 28 Ibid., 2727. 29 McGann et al., A History of the Royal College of Nursing, p. 98. 30 Rafferty, The Politics of Nursing Knowledge, p. 160. 31 Hart, Behind the Mask, pp. 57–64. 32 Rafferty, The Politics of Nursing Knowledge, p. 160. 33 McGann et al., A History of the Royal College of Nursing, p. 99. 34 Ibid., p. 159. 35 Ibid., p. 101. 36 Ministry of Health and Board of Education, Inter-­Departmental Committee on Nursing Services. Interim Report (hereafter referred to as the Athlone Report) (London: HMSO, 1939), p. 57. 37 Ibid., p. 8. 38 E. Sharp, The Labour Woman (April 1932), 53. 39 The Times (4 May 1938), 19.

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Who cared for the carers? 40 H. Balme, A Criticism of Nursing Education with Suggestions for Constructive Reform (London: Humphrey Milford, 1937). 41 Rafferty, The Politics of Nursing Knowledge, p. 162. 42 Athlone Report, p. 20. 43 Ibid., pp. 60–1. 44 Ibid., pp. 51–60. 45 Rafferty, The Politics of Nursing Knowledge, p. 166. 46 Ibid., p. 172. 47 McGann et al., A History of the Royal College of Nursing, p. 128. 48 Kirby, ‘Recruitment, retention and representation of nurses’, 2728. 49 McGann et al., A History of the Royal College of Nursing, p. 132. 50 Ministry of Health, Department of Health for Scotland, Ministry of Labour and National Service, Report of the Working Party on the Recruitment and Training of Nurses (London: HMSO, 1947), chapter II (hereafter referred to as the Wood Report). 51 The Times (16 May 1945). 52 McGann et al., A History of the Royal College of Nursing, p. 136. 53 The Times (2, 30 May 1946). 54 Rafferty, The Politics of Nursing Knowledge, p. 174. 55 Ibid., p. 178. 56 Ibid., p. 57. 57 Rose, Governing the Soul, p. 85. 58 Ibid., p. 50. 59 Wood Report, p. 50. 60 Ibid., p. 54. 61 Ibid., appendix IV, pp. 93–5. 62 Ibid., p. 60. 63 Rafferty, The Politics of Nursing Knowledge, p. 170. 64 R. Nash, ‘Class, “ability” and attainment: a problem for the sociology of education’, British Journal of Sociology of Education, 22:2 (2001), 190. 65 Wood Report, appendix IX, p. 103. 66 Ibid., p. 73. 67 Ibid., pp. 73–4. 68 A. Collins, ‘The embodiment of reconciliation: order and change in the works of Frederick Bartlett’, History of Psychology, 4 (2006), 290–312. 69 Wood Report, p. 62; L. M. Terman and C. Miles, Sex and personality: studies in masculinity and femininity (New York: McGraw-­Hill, 1936), p. 600; L. M. Terman and C. Miles, Manual of Information and Directions for Use of Attitude-­Interest Analysis Test (M-­F Test) (New York: McGraw-­Hill, 1938). 70 Wood Report, p. 62. 71 McGann et al., A History of the Royal College of Nursing, p. 140. 72 Ministry of Health, Department of Health for Scotland, Ministry of Labour and National Service, Working Party on the Recruitment and Training of

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Industrial psychology’s influence Nurses, Minority Report (London: HMSO, 1948) (hereafter referred to as the Minority Report). 73 Ibid. 74 Wood Report, p. 74. 75 Minority Report. 76 P. Starns, March of the Matrons. Military Influence on the British Civilian Nursing Profession, 1939–1969 (Peterborough: DSM, 2000), p. 62. 77 BJN (October 1934), 275. 78 PWDRO, 606/1/15, SDEC general committee minutes, 1 November; 5 November 1933. 79 PWDRO, 1490/27, SDEC Nurses’ Register, 1 November 1932. 80 B. Moseley, ‘South Devon and East Cornwall Hospital’, The Encylopaedia of Plymouth History, www.plymouthdata.info/Hospitals-­SDEC%20Greenbank. htm. Accessed 17 April 2012. 81 Evening Herald (27 July 1942). 82 PWDRO, 606/7/10, Prince of Wales Hospital subcommittee minutes, 4 August 1942. 83 Evening Herald (27 July 1942). 84 PWDRO, 606/7/10, Prince of Wales Hospital subcommittee minutes, 28 January; 4 August; 7 August; 2 September; October 1942. 85 PWDRO, 606/1/17, SDEC house committee minutes, 18 May 1945, p. 92; 23 November 1945, p. 116. 86 PWDRO, 606/1/17, SDEC house committee minutes, 9 September 1943; 23 November 1945, p.116; 19 September 1947, p. 180. 87 BJN (March 1938), 62. 88 S. M. Collins, The Royal London Hospital: A Brief History (London: Royal London Hospital Archives and Museum, 1995). 89 M. E. Broadley, ‘Nursing at The London Hospital in the 1920s and 1930s’, The Review, 49 (September 1980). www.rlhleagueofnurses.org.uk/pdfs/ RLH%20Nursing%20in%20the%201920s%20&%201930s.pdf. Accessed 24 April 2012. 90 BJN (December 1937), 317. 91 RLH, LH/N/1/36, The London Hospital Register of Probationers, November 1931 – November 1932, 9 July 1932, p. 9. 92 RLH, LH/N/1/36, The London Hospital Register of Probationers, 1932, p. 124. 93 BJN (December 1949); (August 1950). 94 RLH, LH/N/6/77, The London Hospital Official Ward Book, 30 December 1944 – 31 August 1945, 21 July 1945, p. 1035. 95 BJN (October 1945). 96 RLH, LH/N/6/77, The London Hospital Official Ward Book, 30 December 1944 – 31 August 1945, 21; 28 July; 30; 31 October; 6 December 1945. Daily Express (8 October 1945).

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Who cared for the carers? Daily Express (8 October 1945). BJN (October 1945), 119. Ibid. RLH, LH/A/12/41, The London Hospital nursing committee minutes, 1947, 7 June 1948. 101 Bevington, Nursing Life and Discipline, p. 27. 102 Ibid. 103 Carpenter, Working for Health, p. 76. 104 RLH, LH/A/12/41, The London Hospital nursing committee minutes, 1947, 7 June; 25 October 1948; 24 July 1950. 105 Ibid., pp. 213–15. 106 Ibid., p. 260. 107 CRO, HC1/1/3/10, Cornwall Mental Hospital Annual Reports, 1920–29. 108 CRO, HC1/1/1/30, Cornwall Mental Hospital Visiting Committee (CMHVC) minutes, 16 June 1933. 109 CRO, HC1/1/3/10, Board of Control Reports, 1926. 110 Andrews, The Dark Awakening, p. 256. 111 CRO, HC1/1/1/30, CMHVC minutes, 27 July 1936, p. 337. 112 CRO, HC1/1/1/34, CMHVC minutes, 29 June 1942; 22 February 1943, p. 439. 113 CRO, HC1/1/1/34, CMHVC minutes, 27 November 1944; 24 September; 29 October 1945; 24 June 1946. 114 Andrews, The Dark Awakening, p. 260. 115 CRO, HC1/1/1/31, CMHVC minutes, 25 August 1941, p. 124; 26 February 1945, p. 134. 116 Kirby, ‘Recruitment, retention and representation of nurses’, 279. 97 98 99 100

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6

Conclusion

By 1948, and the advent of the National Health Service, the care of sick nurses, it was argued, had fallen behind other groups of public and private sector workers.1 The benefits that other workers had seen from the growth of occupational health services, particularly during the two world wars, were thought to have passed nurses by. However, investigating the state of occupational health in Britain in 1949, the Dale Committee concluded that growth was slower than commentators assumed and that most workers’ health care was poor, with few small factories offering any medical service and large firms providing little more than first aid.2 The health care of nurses was comparable to other workers, which, on the whole, had also been neglected. The risks of nursing had been recognised and widely discussed from the late nineteenth century onwards but the state had failed to regulate any provision of care. Understanding why has important implications not just for the history of nursing and the NHS but for the wider question of the history of work. This book has assessed how nurses’ health was managed in the past to gain some insight into why it has become a costly personal, political and economic problem today. The health of nurses was an issue that was always taken seriously at the case study hospitals but each institution approached the problem differently and responses showed much variation over time. There were good reasons for this but the failure to adopt a coherent and consistent policy worked to the detriment of nurses’ health. This difficulty, noticeable at all three hospitals, helps explain the ambiguous treatment of occupational health within wider histories of nursing. This can lead to the erroneous conclusion that occupational health was, somehow, neglected by contemporary actors, thereby facilitating 159

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the omission of the subject from historical studies concentrating on professional projects and the wider politics of nursing. This book takes a different approach. I argue that occupational health issues were inexorably connected to these nursing debates. Occupational health cannot be understood without reference to professional projects. This conclusion can be taken further to argue that an assessment of professional projects and the goals of nursing will be incomplete without appropriate discussion of occupational health concerns. This is as true in debates where occupational health was obscured as it was in cases of overt concern. The professionalisation of nursing had a profound effect on the way nurses’ health was managed. The campaign for nurse registration drew nurses’ health into the political spotlight. Although commentators supported their arguments for and against change with reference to it, nurse leaders did not want to jeopardise their goal of professional status by drawing attention to the health risks of nursing. This set a precedent that suggested that professionalism and a state-­regulated occupational health care system were incompatible. Nurse leaders continued to downplay the occupational risks of nursing long after the Registration Act in 1919 and struggled to escape the vocational ideology inherent in this approach. This was partly because nursing never realised the autonomy that it had hoped for from registration but also because voluntary hospitals continued to set their own conditions of service independently until the Second World War. Furthermore, the College of Nursing’s determination to set itself apart from trade unionism and to establish social as well as educational boundaries impacted on attitudes to nurses’ health. Keen to retain hospital management support during a period of financial difficulties, nurse organisations were reluctant to enforce expensive regulations regarding nurses’ welfare.3 The situation changed during the Second World War when hospital finance improved and the shortage of nurses prompted the government to legislate nurses’ salaries. But despite calls by the King Edward’s Hospital Fund4 and the Prophit Survey to take a more comprehensive approach to occupational health care, no moves were made to enforce hospitals to adopt minimum standards of care.5 The situation was different for asylum nurses, whose work conditions were standardised in 1919. Asylum nurses were not concerned 160

Conclusion

with professionalisation and, as a result, its ideology had very little impact on the management of their health. Managed by doctors rather than nurses and treated as employees, for them this different approach had little benefit as far as health issues were concerned. Indeed, in the late nineteenth century, the issue of nurses’ health was generally ignored by the CLA visiting committee, the medical superintendent and the nursing staff. The risk of physical injury from violent encounters with patients and mental illness from being locked up with the insane were treated as inevitable consequences of the job. These issues were discussed by asylum management only with reference to identification of the patient or nurse responsible for injury, or financial liability during sick leave. As members of an untrained and low-­status occupation, asylum nurses did not lobby for improvements to health care even though the health risks from physical assault were high. With little alternative employment, CLA nurses ignored their own health issues as they tried to accrue long periods of service to qualify for a pension. Attitudes changed during the First World War when the risk of infectious disease rose dramatically. As a result of militant union action in 1918, a standardised scale of pay and uniform work conditions were implemented in asylums across the south-­west region.6 Although this did not include regulation of occupational health care, it meant that the CLA was part of a network where such issues were discussed. From the outset, the notion of professionalism for voluntary hospital nurses involved more than prolonged training and formal qualification and was more about a set of core values whose defining characteristics were self-­discipline and self-­sacrifice rather than skills of clinical judgement and personal autonomy. Debates about nurses’ health obscured the issue by focusing on power, discipline, gender and class rather than identifying what it was about the work that produced a risk of illness. The case studies have revealed how changing social ideas about discipline, gender and class impacted on voluntary hospital and asylum nurses’ health. The theme of power, integral to the debate on professionalisation, is fundamental to understanding why institutions differed in their management of nurses’ sickness. The balance of power to manage nursing departments shifted over time between doctors and nurses and differed between institutions. In the voluntary hospitals, matrons 161

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exerted considerable power to dictate nursing policy but it was subject to medical and lay committee approval and liable to be withdrawn at doctors’ discretion. Matrons like The London Hospital’s Eva Luckes and Claire Alexander gained power by publishing nursing textbooks, implementing a comprehensive system of nurse training and building a strong relationship with medical staff. Provincial matrons, like Harriet Hopkins of the SDEC, hoped that membership of national pro-­registration nursing organisations would increase their standing in the hospital but this proved to be a more precarious strategy. CLA matrons were in a comparatively weak position and never exerted enough power to govern the nursing department independently from the medical superintendent. Uninterested in professional strategies, they were untrained until after the First World War and then played little part in the education of nurses. However, the absence of the all-­ powerful matron in the asylum, usually seen as a barrier to reform, did not seem to aid the identification of health problems. Concerns about the relationship between the matron’s role and nurses’ health were raised in the 1880s. Whilst critics of nurse registration argued that the rapid increase in matrons’ power had a detrimental effect on the way nurses’ health was treated, its supporters hoped that such power would facilitate health benefits to nurses.7 Certainly some matrons influenced improvements to work and living conditions but such power also had negative consequences highlighted by evidence that The London Hospital nurses were too scared to report sick.8 Complaints of hierarchical bullying and intimidation were held up by enquiries into the shortage of nurses during the 1940s as proof that the organisation of nursing needed restructuring.9 This climate of criticism about matrons’ styles of management impacted on the organisation of nursing in the case study hospitals. Doctors at the SDEC became more critical of matrons’ power in the decade between 1932 and 1942 and, having supported matron Lee’s dictatorial management style,10 condemned matron Kenwell’s similar approach ten years later because of her lack of empathy.11 Similarly, matron Littleboy continued to adopt an authoritarian approach when dealing with nurses’ sickness at The London Hospital in 1932 but, ten years later, Alexander introduced a counselling style of management, which encouraged nurses to discuss illness.12 Although she adopted new techniques, she used them to deliver a 162

Conclusion

traditional message of endurance and to retain considerable power over the nursing department. The power accorded to nurse organisations also influenced the management of nurses’ health. Competing factions during the campaign for registration had a detrimental effect on nurse organisations’ influence, which was weak and unable to force improvements to work conditions in the Registration Act of 1919.13 Their powerless position had long-­term repercussions for nurses’ health in so far as it received little government attention until the Athlone Committee in 1939. Nurse organisations’ power was further undermined by their inability to resolve the recurrent recruitment crises of the 1930s and, as a result, government turned to educational and psychological experts to provide solutions to improve nurse welfare. One of the ways both voluntary hospital matrons and the CLA medical superintendent exerted power was by enforcing a strict system of discipline, and this incorporated the treatment of nurses’ health at The London Hospital but not the other two institutions. Changing attitudes to discipline prompted calls for a reassessment of the ways matrons exerted power following the Second World War. Vocational ideology and particularly the notion of self-­sacrifice was an important and persistent influence on attitudes to the health of nurses in the late nineteenth and twentieth centuries. But its influence varied over time and between hospitals depending on the matron’s power and also her political ideas about the best way to professionalise nursing. Anti-­registrationist Eva Luckes attached great importance to the notion of self-­sacrifice as an unwritten code of behaviour that she used to manage an unregulated profession. It acted as a goal for nurses to aspire to as well as a potential threat of loss of employment for those unable to live up to the ideal. She managed nurses’ health by expecting them to tolerate illness as a way of proving their vocation to nurse. The idea that nurses would subordinate their own health needs to those of their patients placed unrealistic demands on nursing staff and made discussion of health a sensitive subject. In contrast, matron Hopkins of the SDEC supported the idea that nursing should be an autonomous, regulated and independent profession. She managed nurses’ health by accepting that nurses’ illness was an almost inevitable consequence of nursing and not a sign of a lack of vocation. The CLA matrons did not aspire to the vocational 163

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ideology espoused by the anti-­registrationists or the professional standards set by pro-­registration nursing organisations. The medical superintendent managed nurses’ health and, as a result, the notion of self-­sacrifice had no influence. Notions of self-­sacrifice and dedication to duty were enduring and continued to be upheld not only as qualifications to nurse but also as justification to resist state regulation of work conditions in the 1920s and 1930s.14 Publicity about nurses’ high risk of tuberculosis alongside recurrent recruitment crises during the Second World War prompted criticism of out dated systems of discipline. Attitudes began to change as industrial psychology influenced ideas about the organisation of nursing. Matrons were blamed for recruitment problems and particularly their disregard for nurses’ feelings. Management and leadership skills concerned with positive mental health were to replace the carrot and stick policies, to which ‘self-­ sacrifice’ had been an integral aspirational goal. These ideas were met with some hostility and resistance. The increasing unpopularity of the rhetoric of ‘self-­sacrifice’ can be explained by the need to attract more recruits to staff the NHS but also reflects wider social changes regarding women’s education and work. Historiography regarding gender and nursing highlights nurse leaders’ use of gender ideologies and imagery to promote their case for professional status.15 This book goes one step further by examining the impact of this relationship on the management of the occupational health of nurses. Ideas about the relationship between gender and nurses’ health changed over time, reflecting wider social debates about women’s position in society. Building on the Victorian ideal that a woman’s place was in the home and that domesticity and motherhood were sufficient emotional fulfilment for women, Luckes claimed that women’s right to nurse derived from their biological capacity for motherhood and their management skills learnt from organising domestic households.16 Such arguments were problematic and whilst a source of strength also created a boundary around health issues. It became difficult for nurse leaders to identify health hazards or demand a reduction in their working hours when the model of motherhood implied a twenty-­four-­hour commitment and a duty of self-­sacrifice. Despite the expansion in educational and career opportunities for women, the ideology of motherhood as a model 164

Conclusion

for nursing was influential until at least the mid-­1920s when it was used to discourage nurses’ support for the state regulation of working hours.17 The influence of gender on ideas about the organisation of nursing and nurses’ health declined during the 1940s. Nurse leaders stopped using the concept of motherhood as a qualification to nurse and a management model and instead were advised to use industrial psychology to structure their management of nurses. Psychological research supported the notion that the ideal nurse was a combination of feminine and masculine qualities, largely because psychologists now considered leadership and an ability to tolerate harrowing sights as masculine.18 Nurse leaders began to promote qualities associated with masculinity in order to gain higher status.19 At the same time notions of femininity lost some of their potency in conversations about nurses’ risk to illness. Commentators continued to draw on gendered vulnerability when discussing TB but more importance was attached to nurses’ social class as an explanation of susceptibility.20 By including male nurses, this book has aimed to redress the balance of a nursing historiography written predominantly, about a female occupation. In contrast to feminist writers in the 1980s who characterised the relationship between men and women as between a dominant self and a subordinate ‘other’, the position was reversed in nursing with women seeking to dominate an occupation by excluding men on the grounds of their ‘otherness’.21 Although the question of registration concerned male and female asylum nursing staff, it was male attendants and their qualification to nurse who received most attention. In a debate that manipulated ideas and ideals of gender, male nurses were portrayed as physical brutes and their ‘manliness’ portrayed as disqualification to care in the acute hospital setting. These negative images sought to define male nurses as ‘the other’ to the ideal female carer. Female attendants were not idealised in the same way as general hospital nurses but the presence of male staff drew attention to the necessary strength and fitness required for the work. Qualities of physical strength were perceived as integral to the male asylum attendants’ job throughout the period studied. An image of physical strength implied immunity to illness. Although attendants regularly complained about their work conditions in the 165

Who cared for the carers?

late nineteenth century, they were reluctant to complain about the risk of physical injury partly because they realised that sickness was antithetical to the qualities of physical strength perceived as integral to their job. As a result, the management of the asylum paid little attention to nurses’ health risk beyond discussion of the asylum’s financial responsibility to its employees. The traditional idea that physical strength qualified men to work in long-­stay wards with heavily dependent, chronic patients or in mental hospitals continued to encourage male nurses towards the more unpopular areas of nursing in the late 1940s. In addition to gender, ideas about social class influenced the management of the health of nurses throughout the period studied. This partly reflects the ways in which class influenced wider understandings of disease but also its centrality to nurses’ campaigns for professionalisation, campaigns that promoted an occupational ideology according to which members were class-­conscious and accepting of a hierarchy. The 1880s marked a crucial phase both to reform and to professionalise nursing. Leading nurses and their lay and medical supporters were keen to attract more middle-­class recruits to raise the status of nursing. It was therefore the special attributes and also vulnerabilities of middle-­class women that framed these discourses. However, over time it became apparent that a focus on poor working conditions was repelling the very recruits that nurse reformers most hoped to attract. This encouraged a new relationship between the promotion of professional projects and health concerns. Either increasingly poor working conditions were denied or the professional nurse was presented as a superior person equipped with sufficient physical and/or mental strength to transcend them. This was particularly noticeable at The London Hospital. By 1947, society’s ideas about the relationship between social class and illness had changed, in part because of research on tuberculosis. Changing cultural perceptions of TB in the general population, that it was no longer considered a hereditary disease of the middle classes but was now linked to the social and environmental problems of the working classes, framed understandings of nurses’ health. Concern that nursing was no longer attractive to middle-­class women, that the number of working-­class nurses was on the rise and that these women were more vulnerable to TB added gravitas to the issue of 166

Conclusion

nurses’ health. As a result, it attracted more importance, but nurse organisations made no attempt to encourage the state to regulate any recommendations made. Hospitals remained at liberty to set their own standards of occupational health care. The history of the occupational health of nurses is important. It offers a new perspective on many of the themes that are central to nursing history, particularly class, gender and the question of professionalisation. The focus on these themes helps us to understand why the management of sick nurses changed over time and varied between different types of institutions. By concentrating on individual nurses’ experiences we reveal something new about the way national conversations affected ordinary nurses’ lives. Recognition that nursing presents a serious occupational health risk is a relatively recent phenomenon, and this book not only sheds light on why nurses’ health attracted little attention before the Second World War but also explains why this situation began to change from the 1940s. The reform process was always likely to be tortuous because the identification of occupational health problems did nothing to resolve the class, gender and professional complications that had already tended to obscure the hazards, thus making them more difficult to address. Notes  1 Bevington, Nursing Life and Discipline p. 20; Industrial Injuries Advisory Council, Report of the Industrial Injuries Advisory Council in Accordance with Section 61 of the National Insurance (Industrial Injuries) Act, 1946, on the Question whether Tuberculosis and Other Communicable Diseases Should Be Prescribed under the Act in Relation to Nurses and Other Health Workers, p. 14; A. Ives, ‘Improvements in conditions of service’, The Times (12 January 1946), 5.  2 Dale Report, appendix E, table A.  3 M. Gorsky, J. Mohan and M. Powell, ‘The financial health of voluntary hospitals in interwar Britain’, Economic History Review, 55:3 (2002), 533–57.  4 King Edward’s Hospital Fund for London, Memorandum on the Supervision of Nurses’ Health, p. 1  5 Ibid.  6 CRO, HC1/1/1/18, CLAVC minutes, 25 November 1918, p. 312.  7 Sandhurst Report, p. 318; RLH, LH/A/17/49, Report of the House Committee on the Allegations which Have Been Recently Made against the Nursing Department, 3 December 1890.

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Who cared for the carers?  8 Sandhurst Report, p. 309; Wood Report, appendix IV, pp. 93–5.  9 Bevington, Nursing Life and Discipline, p. 19; King Edward’s Hospital Fund for London, Memorandum on the Supervision of Nurses’ Health, pp. 5–6. 10 PWDRO, 1490/27 SDEC Nurses Register, 1 November 1932. 11 PWDRO, 606/7/10, Prince of Wales Hospital sub committee minutes, 4, 27 August; 2 September 1942. 12 RLH, LH/A/12/41, The London Hospital nursing committee minutes, 1947, 7 June 1948. 13 Rafferty, The Politics of Nursing Knowledge, pp. 77–87. 14 Nursing Mirror and Midwives Journal (5 July 1919), 258; The Lancet Commission on Nursing, Final Report, p. 29. 15 See Summers, Angels and Citizens, pp. 1–9; Rafferty, The Politics of Nursing Knowledge, p. 25; Davies, Gender and the Professional Predicament in Nursing, p. 58; D’Antonio, ‘Rethinking the rewriting of nursing history’, p. 271. 16 RLH, LH/A/26/5, Luckes, ‘Trained nursing at The London Hospital’, p. 303. 17 NCW, ‘Report of the special committee on the economic position of nurses’, BJN (27 September 1919), 189–94. 18 Wood Report, p. 62. 19 Starns, March of the Matrons, p. 44. 20 Daniels et al., Tuberculosis in Young Adults, pp. 205–13. 21 J. Purvis and A. Weatherill, ‘Playing the gender history game: a reply to Penelope J. Corfield’, Rethinking History, 3 (1999), 333–8.

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181

Index

Abel-Smith, Brian 7, 26, 103 accommodation 20–1, 23, 52, 59, 63, 88–9, 109, 112, 120 Adams, Richard 31, 35, 38 Addison, Christopher 71, 73–5, 93 Alexander, Claire 139, 146–50, 154, 162 Association of Hospital Matrons 74 Asylum Officers’ Superannuation Act (1909) 35, 47 Athlone Report see Interdepartmental Committee on Nursing Services Badger, Theodore 106 Balme, Harold 135 Bankart, H.M.S. 48–9 Barrett, Rosa 87 BCG see Calmette-Guerin (BCG) vaccination Beamont Carter, Gladys 128, 137 Beard, George 79 Bedford Fenwick, Ethel see Fenwick, Ethel Gordon Bevin, Ernest 152 Bevington, Sheila 109, 148 Board of Control 31, 35, 54, 58–9, 150 Bodmin Guardian 56 Boorman, Steve 2–3 Boschma, Geertje 100 Breary, Margaret 79 Bridge, J. C. 46–7 Bristol Asylum 51–3, 58

British Hospitals Association 82 British Journal of Nursing 12–13, 62, 67, 79, 81, 88 British Medical Association 29, 49, 86, 109, 135 British Medical Journal 13, 20, 52 British Nurses’ Association 12, 26–7 Brock, Dorothy 131 Bryder, Linda 102, 114 Burdett, Henry 12–13 Buxton, Olive 102 Calmette-Guerin (BCG) vaccination 116 Central Committee for the State Registration of Nurses 74–5, 77, 93 Charity Organisation Society 12, 39 Cohen, John 130, 138, 140 Coleman, Stanley 151–2 College of Nursing 4, 7, 45–6, 49–50, 60, 65–6, 74–7, 79–90, 92–4, 134–5, 137, 141, 160 Cooke, Marriot 36 Cornwall County Council 150 Cornwall Lunatic Asylum 6–7, 30–6, 50–60, 65–7, 114–16, 150–2, 161–3 Cornwall Mental Hospital 146, 150–4 Cox-Davies, Rachel 76 Crouch, Herbert 86, 92

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Index Dale Committee 120, 154 Dickson, Alice S. 64–5, 113 Digby, Anne 83 Dingwall, Robert 32, 47 diphtheria 19–20, 53 discipline 8, 14–15, 18–19, 27, 33, 37–8, 52, 91, 105, 109, 128, 131–5, 139, 142 Duckworth, Dyce 31–2 Dudley, Francis 45, 51–9 dysentery 53 Edwards, Peter 109 Emergency Medical Service 137 Erwin, Grahame 108, 110 Evening Herald 143 fatigue 11, 46, 78–9, 108, 130, 138 Fenwick, Bedford 12, 17–18 Fenwick, Ethel Gordon 12, 18, 20, 26–7, 29, 32, 39, 74–5, 77–9, 81–2, 85, 88, 108 Fenwick, Samuel 17–18, 22 First World War 7, 45–67, 71–4, 76, 91–2, 102, 113, 130, 135, 151, 161–2 Fishberg, Maurice 107 flat feet 22 General Medical Council 31 General Nursing Council 75, 107, 147, 151 Guild of Nurses 134 Haldane, Elizabeth 87 Harrison, Barbara 4–5 Hart, Christopher 7, 45, 134 Hawkins, Sue 15, 23, 100 Heaf, Frederick 116 Health of Munitions Workers Committee 66 Hecker, Geheimerat 78–9 Heimbeck, Johannes 105–6, 117, 119 Hiney, Margaret 54–8

Hopkins, Harriet 6, 26–30, 37, 62–5, 162–3 Hospital, The 13, 63 Hours of Employment Bill (1920) 76, 80–1 Industrial Health Research Board 46, 130 Industrial Injuries Advisory Council 120–1 industrial psychology 8, 128–30, 148–50, 152–4, 164 infectious diseases 19–21, 28, 45, 53, 61, 101, 161 Interdepartmental Committee on Nursing Services (Athlone Report) (1937) 8, 121, 134–7, 143, 146, 151, 163 International Congress of Nurses 78 King Edward’s Hospital Fund 99, 121, 160 Kirby, Stephanie 100, 133 Koch, Robert 8, 101, 116 Labour Woman, The 135 Lancet 20, 24, 29, 34, 47, 105–8 Lancet Commission on Nursing (1932) 107–8, 130–4, 145–6, 153 Langdon Brown, Walter 108 Lees, C. K. 142–3, 148, 162 Littleboy, Gertrude May 145–6, 162 London County Council 60, 135 London Hospital, The 6–11, 13–25, 111–12, 145–50, 162–3, 165 Lopes, Sir Henry 62 Luckes, Eva 6, 12–26, 37–8, 80, 145, 162–4 Lunacy Act (1890) 31 Lunacy Commission 31, 34 MacCullum, Maude 81 McGann, Susan 87 MacKay, P. M. 102

184

Index male nurses 4, 32, 34, 45, 48, 51–2, 57–8, 66–7, 140–1, 149, 151, 165–6 Mantoux, Charles 105 Matrons’ Council of Great Britain and Ireland 26–7, 29, 95n18 Maudsley, Henry 31 Medical Research Council 100, 116 Medico-Psychological Association 31, 151 Mental Treatment Act (1930) 150 miasmic theories of disease 20–1, 28 middle-class nurses 5, 13, 45, 103, 123, 166 London Hospital, The 15, 22–4, 38–9 Prophit Survey 119 South Devon and East Cornwall Hospital 62–3, 66 Miller, Elizabeth 89 Ministry of Health 73, 75, 93, 117, 121, 137, 141, 148 Ministry of Labour 59, 76–7, 80, 82–4, 137, 144 Minority Report 140 Morant, Sir Robert 75 motherhood 4–5, 21–2, 25, 80, 90–2, 164–5 Mothers’ Union 86 Myers, Arthur 106–7 Myers, Charles 129 National Asylum Workers’ Union 46–9, 55–60, 149 National Council of Nurses of Great Britain and Northern Ireland 146 National Council of Women 85–94 National Health Service (NHS) 1–3, 159 National Institute of Industrial Psychology 129 National Insurance Act (1911) 78, 83 National Insurance (Industrial Injuries) Act (1946) 120

National Union of Trained Nurses 82–3, 86 National Union of Women Workers 85 Nation’s Fund for Nurses 84–5 new woman, the 24–5 Nicholls, E. 83 Nolan, Peter 32 nurses domestic duties 11, 16, 108–9, 140–1, 164 hours of work 1–2, 11, 17, 20, 22, 24, 34, 46–7, 52, 55, 58, 72–3, 76–81, 88, 90 rates of illness 2–3, 13, 45, 52–3, 60–1, 64–5, 89–90, 139–40 salaries 45, 47–52, 58–60, 62, 73, 80, 84–5, 94, 109, 114–15, 134 137, 161 sexuality 48 wastage rates 63–4, 108, 113 Nurses’ Registration Act (1919) 71–81, 91–4, 160, 163 Nursing Mirror 81 Nursing Record and Hospital World 32 Nursing Times 50 Ogilvie Gordon, Marie Matilda 86–7 Ott, Katherine 101 overstrain 73, 78–9 Pall Mall Gazette 1, 13, 24 Parliamentary Recruiting Committee 51 Pearce, Evelyn 137 pensions asylum nurses 34–5, 38, 47, 51, 161 voluntary hospital nurses 85 Perry, Sir Cooper 49, 97 Poor Law Matrons’ Association 86 Prince of Wales Hospitals 142, 144–6, 148, 153 Professional Union of Trained Nurses 81–2, 84 Prophit Survey 117–21, 160

185

Index Queen Victoria Jubilee Institute 82

Summers, Anne 15, 71 Swift, Dame Sarah 49

Rafferty, Ann Marie 26, 32, 75, 107, 138 Report of the Working Party on the Recruitment and Training of Nurses (1947) see Wood Report Rivers, William Gregory 151 Robartes, Sir Charles Agar 62 Royal British Nurses’ Association 29, 32, 74, 83, 86 Rushcliffe Committee 137

temporary attendants 51 Terman, Lewis 140 Thomson, Edith 131 Time and Tide 110 Times, The 74, 108–9, 137 tonsillitis 28, 41n47, 61 Treves, Frederick 17, 22 tuberculosis (TB) 7–8, 99–127, 166–7 typhoid fever 35, 45, 55

scarlet fever 19–20, 53 Second World War 128, 130, 140–4, 151–4, 163–4, 167 Select Committee of the House of Lords on Metropolitan Hospitals (Sandhurst Report) 11–13, 16–23 Select Committee on the Registration of Nurses (1904) 29 self-sacrifice, ideology of 15, 17, 22–4, 37, 45, 66, 80–1, 94, 147, 163–4 septic finger 19, 28, 41n47 Shackleton, Sir David 76–7 Sharp, Evelyn 135 Shaw, H. 57, 59 Shilling Fund 84 Society for the State Registration of Nurses 29 South Devon and East Cornwall Hospital 6–7, 25–30, 37, 60–7, 112–14, 142–5, 153, 162–4 Spahlinger, Henri 115 Spink, Wesley 106 spirituality 77–8 Squire, Edward 104–5 Stanley, Sir Arthur 49, 84–5 Stewart, David A. 106 Stewart, Isla 29

Unemployment Act (1920) 82–4 Valentine, Henry 20–1 violent patients 33, 53, 161 voluntary aid detachment nurses (VADs) 62, 71, 92 von Pirquet, Clemens 105 War Charities Act (1916) 84 Western Morning News 63, 142 Williams, Theodore 99, 103–4 Witz, Anne 26 Wood, Sir Robert 130, 138 Wohl, Anthony 35 Woman’s Leader 92 Worbuoys, Michael 19–20 working-class nurses 4 Cornwall Lunatic Asylum 32, 36, 45, 47, 60 London Hospital, The 13, 15, 22–3 Prophit Survey 118–19 Working Party on Nurse Recruitment and Training (Wood Report) (1946) 8, 130–1, 138–41, 144, 147–9, 152 Young Women’s Christian Association 86

186