CHAPTER 2. Visioning the future by knowing the past
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O’Donohue, who overcame considerable odds to train as nurses and work in Australia’s white healthcare system. To explore this and other fascinating and instructive aspects of nursing history would entail a story of politics, race, social attitudes and geography. It is one of many in Australian nursing history waiting to be told, using the tools of critical history.
• understand the benefits of having a knowledge of nursing’s history
• develop a critical understanding of received accounts of nursing’s history
• identify the lineage of nursing and its occupational relatives
• identify significant events which have influenced nursing’s evolution in Australia, and
• describe aspects in nursing and midwifery that warrant historical research.
HISTORY AND ITS PURPOSE
History, heritage, tradition and the past are concepts that may be familiar to most of us, but what is their relevance to nursing? What is the relationship between knowing about the past and seeing into the future? This chapter is about nursing’s history. It explains why knowing about nursing’s history is useful for all nurses. For some people, history consists merely of important dates, events and celebrated individuals. These elements have a place in history’s narrative, but history has so much more to offer than time lines and famous faces. Some people also think that history is about heritage and tradition, but an Australian historian, Graeme Davison (2000), argues that the concepts of ‘heritage’ and ‘tradition’ are concerned with sentimentality, not the accuracy and objectivity of history that is critical and self-aware. We will return to these concepts later in this chapter.
Why is history important for nurses to know about? Davison writes that, among other things:
History … tells us who we are, gives us an imaginative and sympathetic insight into the lives of others, encourages a critical attitude to question social and political change, and equips us to participate in a political community (Davison 2000:263).
Furthermore, an understanding of history can help to explain how things have come to be the way that they are (Davison 2000). Applied to nursing, for example, we can use the tools of history to examine why nursing is a profession dominated by women. History can also help to explain why some issues in nursing seem complicated, such as Australia’s plan to implement national nursing registration. An examination of social and political developments in the history of healthcare can help us to understand how nursing’s identity as a profession has developed compared with other professions (Connolly 2004).
Sometimes, too, history offers valuable insights into what the future might bring, although clearly it is impossible to be certain what will happen in the future. We can use history to examine the background to current issues and problems. Taking one contemporary concern, the worldwide shortages of nurses and midwives, historical inquiry might explain if these shortages have occurred in the past, and how they were dealt with. Armed with a historical perspective of nursing shortages, it may be possible to shed light on the current situation and to plan future workforces differently. How, then, do we, as nurses, learn about history?
Traditional views of history
Each of us learns about history in different ways. We hear stories and read texts. Sometimes we might ask people about their experiences. A lot of what we have come to accept as nursing’s history derives from popular culture, such as movies and television. Thinking about an ‘image’ representative of nursing’s history, the Australian imagination might picture a neatly frocked Florence Nightingale, carrying a burning lamp in the military wards of Scutari in the Crimean War in the 1850s. We might see a nurse soothing the brow of an injured soldier in World War I, or picture Sister Kenny, the controversial Australian woman who applied novel treatment regimes to children affected by polio. What do these images say about nursing’s history?
These are romantic impressions to say the least. It is likely that most of us have not questioned whether there is any accuracy or objectivity to these images of nursing’s history. This is not surprising, as stories of Nightingale, Kenny and noble nurses have been told and retold. They have come to be accepted as how nursing ‘was’. Commonly accepted interpretations of history are also known as ‘received’ histories. Received histories of nursing summarise this complex history as follows. Before Miss Nightingale’s influence and the later professionalisation of nursing, the care of the sick and childbearing women was unskilled work of low status. The installation of structured training schemes and, later, nursing’s professionalising movement, transformed nursing into a profession for educated women. Received histories, lauding the transformation of nursing from old to new, from darkness to light, were recorded by nurse luminaries in the United States of America by Adelaide Nutting and Lavinia Dock (1907), and in Britain by Sarah Tooley (1906). Nurses in Australia (Webster 1942) and in New Zealand (Maclean 1932) reiterated this triumphal tale.
However, in recalling history as a narrative of progress, received histories inevitably have drawbacks. While they champion the achievements of individuals and celebrate progress, they leave out the more mundane, the contribution of everyday nurses, and those aspects of history which do not ‘fit’ the story of progress. In so doing, nursing becomes distanced from the society it serves. It becomes distanced from the political times in which nurses have lived and worked, from those in which nursing has evolved, from other professions, and from nursing as practice. Until very recently, received accounts of nursing’s history were accepted as accurate. They are now being challenged.
An enlightened view of the past
Recent scholarship in nursing history has questioned the tale of nursing’s triumphs over ignorant nurses through professionalisation and the Nightingale influence. This scholarship applies critical inquiry to history (Dean 1994). Critical history rejects assumptions such as the idea that history is about progress, or that complex events can be explained simply (Connolly 2004). Critical history throws a wide net to examine issues, events, processes and the people who received histories have ignored, so that nursing’s history may be seen in a different light.
One example of groups whose contribution to nursing has not been noted in received histories of nursing is Aboriginal nurses like Sadie Corner (pictured) and Lowitja (Lois)
|Sadie Corner. Reproduced with the permission of the Salvation Army Australia, Southern Territory Archives and Museum, Melbourne.
Here we can offer only a snapshot of nursing’s history. To begin this overview, we look past received history to other explanations of nursing’s evolution. We discuss contemporary nursing’s antecedents and examine the formations of care, using the example of the Australian arena. We consider some historical influences on nursing and some of the events in nursing’s evolution in Australia and New Zealand, and discuss the relationship between history and professional identity. The chapter concludes with remarks on nursing’s future.
THE ROOTS OF MODERN NURSING
Given that the act of nursing is as old as the human race (Nelson 2000), it is difficult to identify nursing’s so-called ‘roots’. However, in the interests of advancing a discussion about nursing’s history, it is useful to agree upon some point in history and work from there. If we agree that nursing in the twenty-first century is ‘modern’, we can attempt to visualise what its antecedents are. Much of contemporary healthcare in the twenty-first century is provided in what we call the ‘modern’ hospital.
The ‘modern’ hospital as a concept emerged in the late nineteenth century, a time when medicine was developing a sophisticated understanding of disease and illness, and experimenting with novel treatments (Rosenberg 1987). The modern hospital was hailed as a complete innovation with its ordered and hierarchical system of caregiving and the emergence of modern nursing, with its hierarchical structures, as parallel in this innovation (Nelson 2000). However, scholars of nursing and health history, including the Australian nursing historian Sioban Nelson (2000), have argued that the idea of the hospital as a place where a systematic care was provided was not ‘new’. Rather, it constituted new ways of doing ‘old’ things in which structure and standards were replicated, but were evangelised as modern innovations. It is in these older ways of providing care that the roots of modern nursing can be found.
In the early Christian era and beyond, care in hospices (early forms of hospitals) was performed by religious communities to those on spiritual pilgrimages (Nelson 2000). Religious orders sought to emulate the work of Jesus Christ in tending to his flock by caring for strangers, the sick poor, providing them a place of refuge, giving nourishment, tending the infirm, and perhaps applying palliative treatments (Nelson 2000). One group of nurses who have sustained this care is the Catholic religious order, the Sisters of Charity of St Vincent de Paul, mentioned later in this chapter. However, the care of the sick poor was not the sole domain of Catholic organisations. Protestant female followers of Christianity, such as Elizabeth Fry, Jane Shaw Stewart, Agnes Jones and Sister Dora [Pattison], in the nineteenth century formed nursing ‘sisterhoods’ through which nursing care was provided to the sick poor in a similar way (Summers 1989). Thus, nursing’s foundations can be found in care in the sick poor as strangers, provided by religious orders as ‘an integral part of Christian practice’ (Nelson 2000:3).
There is of course, another form of care that is not concerned with the Christian practice of caring for strangers. That care is familial care, undertaken conventionally by women as extensions of their roles as wives and mothers (Summers 1988). In the following discussion, familial care is considered within the context of the nineteenth century, a period when Britain was expanding its empire, establishing colonies around the world. With colonial expansion, the customs, conventions and system of government of Britain were carried to new horizons. What was happening in Britain, therefore, impacted on its colonies, including Australia and New Zealand.
The old style nurse
For those with family to attend them, for centuries the person’s home or ‘domicile’ had been the primary domain for the care of the sick, the dying and the place for birth (Summers 1989). This caring work was undertaken as part of familial duties, usually by women; by the nineteenth century and for those who could afford to pay, it was possible to engage a secular (non-religious) nurse to watch over the patient (Summers 1989). These nurses had varying backgrounds, with some relying on their experience of childbearing and rearing, while others, particularly those practising midwifery, were educated by apprenticeship (Evenden 2000). In mid-nineteenth century Britain, popular culture opened a window on the world of the domiciliary nurse via the writings of the social commentator, Charles Dickens. Through one of his serialised novels, The Life and Adventures of Martin Chuzzlewit, published in 1843, Dickens brought to the imagination of the reading public two memorable characters who symbolised all that was perceived to be wrong with nurses and nursing (Grehan 2004).
The Life and Adventures of Martin Chuzzlewit introduced Mrs Sarah Gamp and her friend Betsy Prig. Gamp was a domiciliary nurse and midwife in London attending births, the sick and the deceased; Prig was a hospital nurse who moonlighted as a ‘private’ nurse in people’s homes. Gamp and Prig were depicted as middle-aged, fat, uncouth, drunken, ignorant, unrefined and untrustworthy attendants. Accompanying Dickens’ text were graphic pen and ink sketches of Mrs Gamp and Betsy Prig, leaving little to readers’ imaginations. Dickens’ narratives helped to build perceptions that many nurses were unsuited to the important duty of caring for the sick and for childbearing women, adding to calls for reforms in hospital and private nursing (Grehan 2004).
The ‘modern’ nurse
Calls for a new style of nurse must be considered, not as a result of, but within the context of other developments in society in the nineteenth century. For example, in the Western world at this time, medicine was developing new understandings of diseases and ways to treat them. The modern hospital was the place where medicine’s innovations were carried out; innovations in surgery called for a team of people to guarantee their success (Rosenberg 1987). Nurses providing after care for operation cases needed to be cooperative, literate and diligent, and they needed to be able to observe changes in the patient’s state, using new technologies such as the thermometer (Grehan 2004). Nurses who could perform the new skills required of them were not always easy to find, particularly in the colonies. To understand the development of what is considered in received history to be the era of modern nursing, our discussion continues in the geographic location of colonial Australia and New Zealand.
HEALTHCARE IN EARLY AUSTRALIA AND OTHER COLONIES
As we have noted, colonies transplanted the conventions of their homelands to their new surroundings, so that people who required nursing in childbirth, or as a result of some injury or ailment, were tended at home by the most able member of the family (Grehan 2004). Few records have survived that might explain precisely what nursing constituted in the newly settled British colonial world. It is sobering to consider, however, that care was performed in the absence of modern-day sanitation, where access to running water meant the existence of a nearby stream or perhaps a stagnant pond, where ‘watching’ the patient at night was done by candlelight, and where help in the form of a doctor or nurse might be several days ride away on horseback.
Care provided in the community
As was the case in Britain, governments in Australia tended to leave the responsibility of healthcare to individuals (Grehan 2004). We know from private diaries, letters and administrative documents, including birth registers and coronial inquests, that a variety of people were available to attend the infirm and childbearing women. For example, doctors, nurses, midwives, herbalists, oculists, druggists and dentists were just some of those advertising in the town of Melbourne in 1847 (Port Phillip Almanac and Business Directory). Who the patient chose depended on who was available, what the purchaser expected of his or her care, and what he or she was willing to pay (Martyr 2002).
Birth, for example, was a time when women needed help. Doctors and experienced attendants were not always available, especially in isolated rural areas. Local women often filled this gap, attending births as a neighbourly gesture, or sometimes as paid employment (Grehan & Nelson 2005). A study of births registered in an isolated rural district of New South Wales found that, in the period 1856 to 1896, women were recorded as the primary birth attendant in almost half of the births (Strachan 2001). In some ways, this array of persons was the ultimate in consumer ‘choice’. In reality, however, obtaining an attendant at birth or at times of sickness was a risky business, because there was no real way to measure the qualifications or skills of an attendant. Some nurses were known to have undertaken formal education in midwifery; others had the experience of having their family to rely on (Grehan 2003). Others had no experience whatsoever (Peel 2006).
In the colonial world, where employment for women was hard to find, nursing and midwifery was easily adopted when family circumstances changed. For instance, the Australian nurse historian, Joan Durdin, writes that Mrs Elizabeth Knight, a well-respected midwife in the Mount Gambier region of South Australia, began work at the age of 70 after the death of her husband (Durdin 1991). Women attending others as paid work were known as ‘handywomen’, in the same way that a handyman performs a multitude of tasks around a house (Grehan 2004). These women combined the roles of tending the sick, preparing the dead for burial, acting as midwife, and sometimes running the local postal service too (Forth et al 1998).
As it was in Britain, institutional healthcare in the colonies was a product of the charity sector; some hospitals and asylums in the colonial world were part of the government’s management of prisoners and those deemed to be lunatics (Martyr 2002). Where colonists expanded the white frontier, voluntary hospitals were established in response to industrial catastrophes, such as mining disasters (Collins 1999), but what institutional care was available depended on the geographic locality, the size of the population and its perceived need. The Melbourne Lying-in Hospital and Infirmary for Diseases Peculiar to Women and Children, for example, was established in 1856 for the indigent in the colony of Victoria, mirroring similar institutions in Britain, Scotland and Ireland (McCalman 1998).
The voluntary hospitals, also called ‘charitable institutions’, were established by philanthropically minded people and funded by subscription, so that, in return for their financial support, subscribers were able to recommend people for the institution’s charity (McCalman 1998). However, hospitals were thought to harbour miasmas, noxious vapours said to emanate from suppurating wounds, ill-ventilated rooms, cesspits and cemeteries (Nelson 1998). According to mid-nineteenth century medical orthodoxy, diseases were a result of absorption of miasmas; the practice of ‘sanitary’ science was the method to minimise them (Nelson 1998). Sanitary science and miasmatic theory demanded an extensive regime of cleanliness and ventilation practices for this purpose, and the exclusion of certain conditions from hospital admission. Among them were smallpox and forms of cancer (Bashford 1998). Pregnant women were excluded from hospital admission, too, because healthy people were thought to be at risk from miasmas.
Just as in Britain, hospitals in the colonial world were hierarchical places. What a nurse was expected to do depended on the type of establishment in which she was employed, and on what basis she was employed—that is, as head nurse, assistant nurse or pupil nurse. In the colony of Victoria, for example, hospitals might be operated by a married couple as attendants who provided food, did the laundry and attended to the patients; other establishments employed men as nurses (Collins & Kippen 2003). According to the dictates of sanitary science, the nurse’s role in maintaining the cleanest possible environment, through promoting fresh air and cleanliness, was of paramount importance (Nelson 2000).
Given that hospitals were not sewered until the late nineteenth century, it was also the nurses’ job under this regime to dispose of bodily wastes such as blood, faeces and urine. Excreta were placed in buckets stored at the end of wards and later thrown out into a cesspit within hospital grounds (Templeton 1969). Institutional nurses’ work also included scrubbing floors, brushing carpets, dusting, polishing brassware and furniture, washing the patients and providing nourishments for those who could not do it for themselves. Nurses had to clean and fumigate straw mattresses, known as palliasses, in special airing rooms (McCalman 1998). They carried soiled linen to the laundry for washing. In some hospitals they slept at the end of wards so that they could attend people when required.
Mid-nineteenth century nursing consisted of a mixture of bedside attendance and lots of domestic work. It was extremely hard work for little reward. Little wonder, then, that few people were attracted to the position of ‘hospital nurse’ and the descriptor of ‘Sarah Gamp’ was applied to many of them (Grehan 2004). Those who applied for positions at Melbourne’s Lying-in Hospital in the nineteenth century, for example, either as nurses or pupils, had to provide a testimonial or letter from a minister of religion or medical practitioner as a recommendation that the hospital employ them. This was designed to weed out potential troublemakers (McCalman 1998). However, even with these attempts at control, nurses were found wanting in their behaviour, had bad language, were drunk on duty and were cruel to patients (Grehan 2004). What is clear is that we hear only about those nurses who did not comply with institutional expectations. This quirk in nursing’s history is not so surprising. As the American historian Laurel Ulrich has noted in the title of her recent (2007) book, ‘Well behaved women seldom make history’!
Institutional training schemes
In the last quarter of the twentieth century, as the expansion of the modern hospital created a demand for more staff, hospitals introduced their own training schemes for nurses. Training, it has to be said, was far less sophisticated than the term suggests. It involved on-the-job learning, combined with lectures by medical practitioners, which pupil nurses attended only if they could be freed from their ward work (Mitchell 1977). Hospitals, always starved of funds, sometimes hired out pupil nurses to nurse private paying patients in their own homes, meaning that pupil nurses could spend a substantial portion of their training time away from the hospital, learning very little (Templeton 1969).
Another issue was that training tended to be organised around the institution’s associated medical speciality, so that wildly varying schemes proliferated and a lack of uniformity in training was the outcome. For example, a training scheme in a hospital established for people with eye and ear conditions produced eye and ear nurses. Training was so specific to the hospital’s needs that the ‘trained’ nurses’ skills were not always transferable to another environment (Trembath & Hellier 1987).
Nightingale trained nurses
Given the reported variability in nurses, their care, and the low status of nursing, it is not surprising that Miss Florence Nightingale’s ideas about training nurses were seen as necessary solutions to the various ills pervading colonial healthcare. When news emerged that Nightingale was to establish a training school where nurses could be trained ‘properly’, the Australian public embraced the idea (Argus, 10 July 1856).
In Britain, a charitable organisation known as the ‘Nightingale Fund for Nursing’ was founded in 1856, to commemorate Nightingale’s work with the Crimean War wounded. Headed by a group of social reformers, not Nightingale herself, the Nightingale Fund wanted to support nurse training in institutions all around the colonial world. The Nightingale Fund’s enduring message was that nursing needed educated ‘ladies’ of good character who could act as role models for the less educated nurses around them (Baly 1987). Under the auspices of the Nightingale Fund, two training schools in London were established. One was for general nursing at St Thomas’s Hospital; the other was for midwifery nursing at King’s College Hospital, although it lasted only for five years (Baly 1987). The so-called ‘model’ of Nightingale nurse training spread to hospitals throughout the English-speaking world.
Nightingale nursing was introduced into New South Wales with much fanfare in 1868 after Sir Henry Parkes, then Colonial Secretary of New South Wales, requested the Fund’s help to improve conditions at the Sydney Hospital (Godden 2006). Miss Lucy Osburn arrived in Sydney in 1868, ready for reform with the help of five Nightingale nurses. This episode in Australian nursing has been much celebrated (Godden 2006). But recent research by Judith Godden, an Australian historian, shows that reports of the Sydney Hospital’s condition were greatly exaggerated, and that Osburn’s capabilities as a nurse were of similar, mythical proportion (Godden 2006). Nevertheless, the idea caught on that colonial nursing desperately needed cleaning up and that Nightingale nursing was the prescribed method to effect it. In 1885, the Australian colony of Tasmania welcomed three Nightingale nurses to institute reforms in that colony (Grehan 2004). The Nightingale Fund’s two-tiered model of pupil nurses being ‘lady nurses’ and ‘regular probationers’ was subsequently adopted throughout Australia (Grehan 2004) and in New Zealand (Hill 1982) to much acclaim.
The story of modern nursing as having emerged through the reform of hospitals, as well as private and institutional nursing, with systematised training and professionalisation, is the received version of nursing’s history. However, nursing and hospital reforms came very, very slowly in the colonies, just as they did elsewhere. There was little agreement on how to run hospitals, on how to teach nurses, what to teach nurses, and even on whether training was beneficial (Grehan 2004). Reforms in nursing and hospitals were just one small element in a wave of rapid and lasting social change in the mid-nineteenth century (Nelson 2000). In the early years of the twentieth century, a degree of uniformity in nurse training schemes was achieved, although this was a lengthy and complicated process, discussed later in this chapter.
Earlier in our discussion about the deficits of received histories of nursing, we noted that these accounts tended to celebrate milestones and ignore other aspects of nursing and healthcare. Given the profile of ‘Nightingales’ in received histories of nursing, one can be forgiven for imagining that there were no skilled nurses in Australia and very low standards in healthcare until 1868. However, as early as 1838, five religious nurses from Dublin were providing care in Sydney, 30 years before Miss Osburn set foot in the colony. Of these five Catholic Sisters of Charity, one had trained as a nurse; another had been sent to Paris to gain nursing experience (MacGinley 2002). The Sisters visited Parramatta’s female factory, the women’s jail and ‘the sick poor in their own homes’ (MacGinley 2002:72). In 1857, the Sisters of Charity opened the first St Vincent’s Hospital at Sydney’s Pott’s Point. Today, the St Vincent’s hospitals provide a considerable proportion of public health services.