Nursing and nursing professionalism

Chapter 9. Nursing and nursing professionalism

Hannah Cooke





Origins and development of modern nursing


Nursing as an occupation has been carried out throughout history. We have records of nursing from ancient Greece and Rome, as well as in early Islamic society. Nursing as a separate occupation often formed part of domestic service but soon also became part of a religious vocation. Within Christianity, nursing formed part of the work of religious orders and these were to have a decisive influence on the creation of the modern occupation of nursing. It is clear that in earlier times, there were no rigid divisions between nursing and other forms of healing in the same way that there was no rigid distinction between care and cure (Stacey 1988). Stacey classifies healers as domestic, folk or professional but the boundaries between these three categories were often blurred. Much healing occurred in the domestic sphere and women learnt home remedies as an integral part of learning to manage the home. In addition, a variety of paid healers might also be consulted. For example, a wide range of different types of healer existed in Tudor England including physicians, apothecaries, barber surgeons, bone-setters and folk healers (described as ‘cunning men’ and ‘wise women’). Approximately one-third of healers were women (Stacey 1988). Although professional physicians were the elite, even the wealthy sometimes made use of folk healers whose traditional techniques had often been tried and tested over centuries, and thus were sometimes more effective than the physicians’ remedies.

Nursing as we know it today began with the nineteenth-century reforms of nursing which established what at that time was described as the ‘new model nurse’. Nursing reform was closely linked to the rise of the medical profession and the creation of modern scientific medicine. The rise of modern medicine began in the eighteenth century and was closely associated with the French revolution and the period that we now describe as the ‘Enlightenment’ (Porter 2003). Gradually, other forms of healer (especially women) were driven out of the marketplace culminating in the Medical Registration Act in 1858, which established medicine as a state regulated profession.

The growth of modern medicine was associated with the growth of the hospital system which began in France and continued throughout the nineteenth century. Doctors were now often working in an institutional rather than a domestic sphere. Furthermore, Jewson (1976) argued that modern scientific medicine marked the death of ‘bedside medicine’; a process which Foucault has described as a change in the medical ‘gaze’ (Foucault 1973, see Chapter 8). The new public hospitals in France allowed mass observation of the sick and for the first time a patient’s symptoms could be correlated with pathological findings after death. This was the beginning of the new anatamo-clinical medicine (Porter 2002) and as doctors moved the focus of their attention from the bedside to the laboratory, the need for a reliable worker at the bedside, to observe the patient and carry out doctors’ instructions, became apparent. Doctors thus wanted a better educated helper who could, for example, read medical prescriptions and drug labels.



Mary Seacole (1805–1881)



Mary Seacole was born Mary Grant, in Jamaica. She was the daughter of a free-born Black Jamaican woman and a Scottish soldier. She learnt nursing skills by working with her mother, who ran a boarding house for invalid British soldiers. She travelled widely in the Caribbean and Central America and became well versed in both traditional and modern medicine. She married Edwin Seacole in 1836 but was widowed in 1844. In 1854, she travelled to England to offer her services as a nurse in the Crimea, hoping her many years’ experience nursing British soldiers could be put to good use. Her services were refused by the War Office and it seems likely that this refusal was motivated by racism. Undaunted, she travelled to the Crimea and set up her own hotel for wounded soldiers. She was notable for her presence on the battlefield and the war correspondent W H Russell described her as ‘a warm and successful physician, who doctors and cures all manner of men with extraordinary success. She is always in attendance near the battle field to aid the wounded, and has earned many a poor fellow’s blessings’.

She returned to England destitute in 1857 and a charitable subscription was set up for her by her supporters who were angered that Florence Nightingale had been feted, while she had been forgotten. She published her memoirs in 1857. She spent the rest of her life in Britain, dying in obscurity in 1881. Mary Seacole was forgotten for many years but there was a recent revival of interest in her life and her memoirs have been republished.

Opinions have been divided as to the quality of nursing prior to the reforms of Florence Nightingale and her contemporaries. According to Abel Smith (1960), prior to nursing reform, hospitals employed women of the ‘charwoman class’ and their limited abilities reflected their poor pay and conditions. He records that provincial hospitals at this time offered nurses a weekly wage of 2s 6d at a time when a wage of 9s 6d could be obtained for work in a cotton mill. It was small wonder therefore that many hospital nurses during this period were old, infirm and illiterate. Florence Nightingale and her fellow reformers portrayed the nurses of their times in the worst possible light in order to engage support for their political project. Nevertheless, Dingwall et al (1988) suggest that their claims may have been exaggerated. They record that doctors had begun to reform the education and working conditions of nursing staff prior to the reforms of Florence Nightingale and her contemporaries and that by no means all nurses were the illiterate drunkards portrayed by nurse reformers, such as Nightingale and immortalized by Charles Dickens in the characters of Mrs Gamp and Betsy Prig (Dickens 1844). For example, Mary Seacole whose story has recently been rediscovered (Seacole 2004) has been described as the ‘black Florence Nightingale’. She worked on the front line in the Crimea and was plainly a skilled and dedicated nurse. By contrast, Nightingale’s ladies worked in the safety of a hospital and there were strict limitations to their role in ‘hands on’ care.

A variety of motives inspired the nursing reform movement. We can see that there was a distinct demand for a new type of hospital nurse to act as an adjunct to medicine. Some nursing reformers, although worried that nurses were incompetent, were even more preoccupied by their moral failings. This reflected wider concerns about the growth of the urban working class and the threat that they represented to the new economic and social order as Kay’s contemporary report illustrates.

‘The evils affecting the working class so far from being the necessary results of the commercial system, furnish evidence of a disease which impairs its energies if it does not threaten its vitality … Want of cleanliness, of forethought and economy, are found in almost invariable alliance with dissipation, reckless habits and disease. The population gradually becomes physically less efficient as producers of wealth – morally so from idleness – politically worthless as having few desires to satisfy, and noxious as dissipaters of capital accumulated’(Kay 1832).

Nursing reformers wanted the sick poor to be nursed by obedient and respectable women who would remind them of their Christian duties. The reform of nursing was seen as an important factor in the attempts to cleanse and moralize the poorer classes and thus can be seen as part of the new institutions of social control that grew up in the industrial era (Dingwall et al 1988). The growth of the industrial working class during the nineteenth century was seen as a pressing social problem. This was partly based on compassion for the conditions of the working class and concern at their appalling conditions, but perhaps even more due to a desire to contain the poor for fear that they might riot or spread immorality and disease. As we noted in Chapter 4, the discipline of the new industrial system was often resisted and draconian social measures, such as the workhouse, were employed to ensure its success. This was what Scull (1977) has called the ‘era of incarceration’ when the poor, the sick and the deviant were locked away in a wide variety of specialist institutions such as prisons, workhouses, asylums and sanitaria. The ‘discovery of the asylum’ (Rothman 1971) during this era created institutions where the poor were expected to learn new habits of cleanliness, order and obedience. Nurses played an important part in the growth of these new institutions but they also played an important role in the regulation of the poor in their homes, communities and workplaces. A number of schemes were organized to arrange ‘lady visitors’ to the poor to impart lessons in Christian morals and domestic economy. We can trace modern health visiting back to these early schemes.

So far, we have seen that modern nursing owes its origins to the need for a new more skilled helper for the medical profession and also to a Victorian preoccupation with the moral reform and containment of the urban poor. According to Dean and Bolton (1980: 80):

‘The nurse was to be one element in the rich ensemble of techniques which were elaborated in the later nineteenth century so that the health, sexuality, sanitation and moral behaviour of the population could become an essential part of the art of government’.

A further factor in the rise of modern nursing was the need of many middle and upper class spinsters to find careers which freed them from their dependence on male relatives. Women who were unwilling or unable to find husbands had few opportunities to earn a respectable living. In the mid-nineteenth century, there was a very real concern about the ‘problem’ of ‘surplus women’. Many of the early nurse reformers were ‘surplus’ middle class spinsters and these lady reformers aspired to a new career directing the lower orders of nursing just as their married sisters directed their household servants. The links to domestic service were strong. Summers (1989) has suggested that the rise of the middle classes brought changes to domestic service which fed the demand for a new class of nurse in the private sphere as well as in the hospital:

‘In the 1840s and 1850s new conventions were being established for the hierarchy, dress and behaviour of female domestic servants. They were to wear the uniform of the household, to speak only when spoken to, to know their place and to answer, very often, to a name of their employer’s choosing. Gamp, Prig and Woodward represented a survival of earlier conventions: their clothes did not blend with the décor, they occupied no fixed rung in the service hierarchy, they were addressed by their own names, and they expected to be able to voice, and even enforce, their own opinions’.(Summers 1989: 373)

Thus, the faults of nineteenth century private nurses included their ‘vulgarity’ which caused offence to their middle class employers and their alleged ignorance and insubordination which offended both the doctor and employer. Summers suggests that the movement for nursing reform was ‘many stranded’, bringing together:

‘male physicians and surgeons, religious reformers of both sexes, and all those anxious to expand professional opportunities for women’(Summers 1989: 365).

Thus, the demands of doctors and middle class employers for a more reliable and biddable employee became linked to social and religious reformers’ attempts to cleanse and moralize the poor and also, ironically perhaps, to the movement for female emancipation. Since so many contending interests became involved in the reformation of the nurse it is not surprising that the ‘new model nurse’ was to be all things to all people as is manifest in the lengthy list of virtues that reformers of this era expected her to display. For example, Eva Luckës, Matron to the London Hospital, required the following:

‘Nurses are required to be truthful, obedient, punctual, calm, cheerful, pleasant, clean and neat. It is important that they should bring the valuable qualities of memory, forethought, and method to bear upon their work, in addition to the essential characteristics of unselfishness and a genuine sympathy with suffering … Well-managed hospitals afford abundant opportunities for the necessary exercise of the very qualities that need strengthening and developing in the characters of most women. By faithfully carrying out the rules laid down for her guidance, an intelligent nurse will soon appreciate the fact that many of them are calculated to help her far more than she would have imagined possible. But it is only those who are prepared to accept this temporary rule of life in the right spirit who will derive full benefit from it’.(Luckës 1899: 11)

We can sum up the contradictory expectations imposed on the ‘new model nurse’ in the phrase ‘intelligent obedience’. Nurses were expected to exercise independent judgement but also to know when to be submissive. They were expected to be intelligent but not too intelligent. They were expected to have a degree of medical knowledge but never to question a doctor’s judgement. These contradictory expectations have continued to influence the development of nursing as an occupation to this day. The rationale behind these contradictory ideas was the ‘separate spheres’ theory of a gendered division of labour (Rafferty 1996). Men and women in the workplace should have different roles and areas of jurisdiction just as they did in the household.


The woman credited with the creation of the nursing profession was Florence Nightingale. She subscribed firmly to the doctrine of ‘separate spheres’ stating that ‘nursing and medicine must never be mixed up’ (cited in Rafferty 1996). We can see many contradictory ideas expressed in her writings and more starkly in the myths that have come to characterize the many and varied stories of her life.

According to Whittaker and Oleson (1964), the story of Florence Nightingale’s life has become a ‘heroine legend’ and Dingwall et al (1988) note the difficulty of separating myth from reality. Different aspects of the Nightingale myth appeal to different groups and her story has been used to lend support to a multitude of conflicting causes. Early popular biographies claimed that she had an innate desire to care and nursed and bandaged her dolls from the earliest age, thus emphasizing her support for traditional female roles. By contrast, other authors have presented her as an early feminist and seen her nursing reforms as ‘an instalment of the emancipation of women’(Abel Smith 1960). Nursing traditionalists presented her as ‘the lady of the lamp’, selflessly devoting herself to the care of her patients and used her story to justify long hours and poor working conditions (Godden 1997). In contrast, her administrative rather thannursing skills have been emphasized by those advocating increased managerialism. The Griffiths report (1983) which introduced ‘general management’ into the NHS stated:

‘If Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge’.(Griffiths report 1983: 12)

Ironically, Griffiths used the Nightingale myth to justify axing nursing managers and putting nurses under the control of ‘general’ managers. More recently, Nightingale’s ‘passion’ for statistics has been highlighted to claim her as a founder of the ‘evidence-based practice’ movement (McDonald 2001). Her religious writings still attract the attentions of evangelical Christians and some contemporary supporters of evidence-based practice might be surprised to learn that she regarded statistics as a ‘religious service’, which enabled statisticians to know the ‘character of God’.

Florence Nightingale (1820–1910)




Nightingale was born in Florence in 1820 to an affluent and influential family. She expressed an interest in nursing during her 20s and developed a connection with religious Sisterhoods, which led to her studying with a Protestant nursing order at Kaiserwerth during 1850 and 1851. In 1853, she became superintendent of a charitable institution for sick ‘gentlewomen’. According to Dingwall et al (1988), she modelled her superintendence on the management of a large household and had strict ideas about economy, discipline and moral order. The results of her superintendence were sometimes unfortunate. During her 12 months stay, she imposed rigid rules and economies on the inmates whom she regarded with deep suspicion. She is also said to have got through two complete sets of servants. Her ideas nevertheless impressed social reformers of the time, leading to her being asked to lead a party of nurses to go out to the Crimean war. Her impact remains controversial. She and her supporters claimed that her intervention was an astounding success leading to a dramatic fall in the death rate. Detractors expressed reservations about these claims (Summers 1988). Whatever the facts of the case, following her return from the Crimea, Nightingale was treated as a national heroine who came to have an enormous influence over the reform of nursing, even though she spent most of the rest of her life confined to bed by a mystery illness. She was asked to oversee the reform of nurse training at St Thomas’ Hospital, and the ‘Nightingale School’ became the pattern for the training of the ‘new model nurse’. Nightingale was a prolific writer and her ideas remain influential. She believed in ‘sanitary’ reform, saying that hospitals should ‘do the sick no harm’. Light, quiet, cleanliness, fresh air and good diet were central to the fight against disease. She was a keen statistician and saw statistical analysis as essential to hospital administration. She pioneered the comparison of hospital death rates and is credited with the invention of the pie chart (Maindonald and Richardson 2004).

If the story of Nightingale is riven with contradictions then so also is the development of nursing from its earliest origins to the present day. We will consider these contradictions throughout this chapter beginning by looking at the gendered nature of the occupation. To what extent is nursing ‘women’s work’ operating in a ‘separate sphere’ from medicine as Nightingale suggested?


Nursing as women’s work?


According to Eva Gamarnikow (1978), early nursing theorists based their ideas on biological determinism. They believed it was ‘natural’ for women to care and for men to take charge. The division of labour between doctors and nurses was based therefore on the ‘natural’ order of things. Writing from a feminist perspective Gamarnikow challenged these ideas. She saw the division of labour between doctors and nurses as social and not biological. She said that doctors had ‘defined femininity in terms of the patriarchal feminine subordination to safeguard their own dominance’. She pointed out that the roles assigned to doctor, nurse and patient replicated the roles of father, mother and child within the Victorian household (for a further discussion of roles within the family, see Chapter 2). The doctor gave the orders, the nurse carried them out, the patient did as he was told and like the Victorian child, was expected to be ‘seen and not heard’. We can see therefore that this division of labour had many drawbacks for patients as well as nurses.

According to Hart (2004), this association with the ‘oppressed mother’ has long oppressed nursing. Just as the father was defined by his work, so the doctor has clear parameters to his role. The nurse however just like the mother must always ‘be there’ and is thus expected to get on and cope with anything and everything else. This ‘unlimited liability’ (Aldridge 1994) has had a profound and often negative impact on the status and working conditions of nurses. In particular, it has made it extraordinarily difficult for nurses themselves to define the boundaries of nursing. We will return to this issue later.

Extending this domestic metaphor, Stein (1967) described a ritual of nurse–doctor interaction which he called the ‘doctor–nurse game’. Nurses and doctors played out traditional gender roles in the workplace. The nurse had to learn to make suggestions to the doctor without undermining his authority or appearing to be openly assertive. She learnt to make treatment recommendations covertly in such a way that they appeared to be initiated by the physician. Nurses were therefore expected to adopt a role which conformed to the stereotype of the wife who used ‘feminine wiles’ to get round her husband rather than being allowed to adopt the role of an assertive and respected professional. To put it in the language of Hochschild (1983), the nurse was expected to engage in emotional labour (see Chapter 4) in order that the physician could save face. In 1990, Stein ‘revisited’ the ‘doctor–nurse game’ and noted that nurses had ‘decided to stop playing the game’ and had become more openly assertive (Stein 1990). What had changed to bring this about?

The nineteenth century nurse reformers were trying to build a professional career for nurses at a time when few other occupational opportunities for women existed. Given the attitudes to women at that time, this was no mean achievement. A century later, economic and social conditions had changed dramatically. New rights for women in the workplace were coupled with a growth in service sector employment where ‘soft’ skills such as caring and communication traditionally associated with women workers were in high demand. Nursing was only one career out of many that women could choose to pursue.

The gender structure of healthcare changed markedly in the late twentieth century. Male nurses were not admitted to the Royal College of Nursing until 1960 and prior to this period, male nurses were concentrated in mental health nursing and were members of trade unions. Gradually, general nursing began to open up to male nurses who quickly came to assume a disproportionately higher number of senior positions than their numbers would merit (Hart 2004). Men make up around 10% of the nursing workforce but occupy approximately 40% of senior posts. Male nurses are over-represented in nursing management, research and education (Miers 2000). During the late twentieth century, the numbers of women in medicine began to climb, and by the 1990s, 50% of medical students were women. The traditional ‘doctor–nurse game’ had become outmoded and in many situations, nurses had become more assertive (Allen 1997). This did not necessarily imply an end to gender inequalities in healthcare but that they were no longer ordered simply around the doctor–nurse relationship.

In these circumstances, the nurse’s role as a doctor’s ‘handmaiden’ had come to be openly questioned and nurses had developed a range of strategies to assert their professional independence. Education was seen by many as the key to professional advancement and by the end of the century, nurse education had transferred to the university sector and nurses had developed their own body of theory and research. However, the impact of these changes on the realities of nursing at the bedside was a matter of some debate (Dingwall & Allen 2001). What exactly was the nature and purpose of nursing professionalism?

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Feb 17, 2017 | Posted by in NURSING | Comments Off on Nursing and nursing professionalism

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