The American Association for the History of Nursing is so pleased to partner with Nursing Clio for this special series, which showcases some of the innovative and diverse work being done by historians of nursing across the world. The AAHN holds its annual meeting this week in Rochester, New York, and these essays are windows into the kind of questions and issues being explored at that meeting, by historians who use nurses as a lens through which to understand the intersection between gender, work, and health. Nursing history did not start with Florence Nightingale, nor is it at an end. As nurses continue to make up the largest health care workforce, practicing their art and science in a variety of settings, communities and political contexts, it is more important than ever that we look to where we have been to learn the lessons we need for the future of increasingly complex healthcare systems. Whenever I talk to students or fellow scholars about the significance of nursing history, especially at the moment, I emphasize the significant social role that nurses have played. Nurses have had to negotiate sexism and racism within society, and within their profession. They have been continually challenged by hierarchies of medicine, power, and authority as they attempted to provide care, as historian Susan Reverby has argued, in a society that does not value caring. And they have not always been angels of selfless good. Yet nursing continues to be the most trusted of all the professions, and that trust is something that has been, and continues to be, earned. These essays from the history of nursing demonstrate the complex ways in which nurses have striven to provide careful, compassionate, patient-centered care, and how they have always been agents of social change.
Dr Kylie M Smith
Andrew W Mellon Faculty Fellow for Nursing & the Humanities
Emory University, Atlanta Georgia.
Director and Chair of Communications
American Association for the History of Nursing
What made a “proper” nurse in the late eighteenth and early nineteenth centuries? Both the Royal Navy and the British Army outlined their desire for female nurses in their regulatory literature. The army desired a “careful, cleanly, and active woman accustomed to the charge and management of sick persons,” while the navy called for “not less than one proper nurse for every ten men,” for its naval hospitals.1 On the surface, the requirements for nurses in the army and the navy were the same — women used to the care of the sick by virtue of their feminine nature and experience — yet, the perceptions of nurses and the roles they were tasked with differed greatly between the two services.
Nursing in the Army
Medical professionals saw the act of nursing as an almost universal skill for most women, though when given the choice they preferred to offer the role of army nurse to the wife of a non-commissioned officer.2 The first official regulation book for regimental hospitals, issued in 1799, followed an overhaul of the military medical hierarchy, but had little to say about either nurses or nursing. The nurse was to “prepare the slops and comforts for the sick, and occasionally to assist in administering medicines, cooking the victuals, washing, &c.”3
These tasks all fell under the purview of traditional gender roles in the early modern period. Although additional regulations were issued in 1803, 1806, and 1812, they are notable for how little the role of the nurse was delineated, especially when compared to increased oversight and universal standards for army surgeons.4 The only additional task that was added to the above list of duties was that of cleaning the ward.5
Some medical officers praised the work of female nurses. Robert Jackson believed that “Intelligence and tenderness are conspicuous in the female character; and, on this account, female nurses are selected for the chief care of the sick in hospitals.”6 Others like John G. V. Millingen viewed nurses with suspicion: “personal attendance upon the sick is seldom if ever of use, and their presence in the wards, which such an attendance would require, is always a source of altercation and confusion both amongst the patients and the orderlies.”7
Yet official regulations stated that they were viewed as replaceable or interchangeable with male orderlies pulled from the army’s ranks. If the regiment was split into cantonments then the wages of the nurse were to go to pay for three orderlies, one to be stationed with each detachment.8 Although some medical officers clearly felt the work of nurses was beneficial to the running of their hospitals, others saw them as a nuisance. Most importantly, during a time of increased centralized medical organization, the army regulations decreed that female nurses were directly replaceable with male orderlies in certain instances.
The “Jill of all trades” characteristics of regimental hospital nurses is not surprising given that the regimental hospital was the primary site of medical treatment in the military medical system. Such hospitals were designed to be small, movable, and able to handle ordinary everyday medical care, and not necessarily the complex realities of massive battle casualties, amputations, and severe disease outbreaks. These sorts of complex medical cases might be initially assessed by a regimental surgeon, but were then meant to be transported up the line to general hospitals.9
With the relatively small scale of regimental hospital operations, and the continual relocation of regimental medical services, the army saw no need to change how regimental hospitals operated and did not attempt to enact comprehensive reforms. Rather than question the staffing or operation of regimental hospitals, medical officers praised the regimental system for avoiding overcrowding, possessing adequate ventilation, and allowing patients to be treated by familiar medical officers.10
Nursing in the Navy
Eighteenth-century regulation of naval nurses predates the opening of Haslar and Plymouth, the navy’s clinical hospitals, but it is clear that the experiences of nursing in these institutions influenced future regulations. The initial regulations issued for the opening of Haslar in 1753, and copied for the opening of Plymouth in 1760, contained seventeen articles. Commissioners of the Sick and Hurt Board, from the beginning, saw naval hospital nursing as more complex than nursing in the army. Most of these articles addressed the behavior of both nurses and patients, such as drunkenness, quarrelling with patients or fellow nurses, and mandatory attendance at chapel.11
The specificity of the list of misbehaviors of both nurses and patients in these articles suggests that the regulations were issued in response to a myriad of misbehaviors currently occurring in naval hospitals. However, there are some distinctly medical regulatory articles in the initial nursing regulations. Impurities, such as “dirt, bones, or Rags,” and “foul Linen whether Sheets or Shirts,” were to be removed from the ward environment and its environs.12
Ward divisions were to be reinforced and contagion limited by the rule that “no Hospital Dresses or any part of that dress be carried out of the Fever, Flux, or Small-Pox Wards into other Wards.”13 Nurses were also to carefully monitor their patients’ state of health: “That if any Men are taken ill in the Recovery Wards so as to be obliged to take to their Beds the Nurses do acquaint the Hospital Mate in waiting therewith that they may be immediately removed if that shall be judged necessary.”14
The initial nursing regulations for Haslar and Plymouth illustrate that nurses were a complex entity in the hospital establishment, providers of medical care and monitors of behavior, but a group who also had their own behavior policed. Overall, the hierarchical framework of naval hospitals was better established than that of the army, owing to the fact that these institutions were in constant operation even during times of peace, while the army needed to re-establish a new medical framework for each military campaign.
Naval nursing regulations were continually revised for the rest of the century, with the role of the nurse becoming both more medicalized and more clearly defined, culminating in the first printed naval hospital instructions in 1808. By this time, nurses had clear positions of authority in their wards, a seniority system, and full integration in all facets of the hospital.15 The critical role that nurses played in the functioning of the hospitals was underscored by their mention in all sections of the regulations, including those discussing the conduct of surgeons, dispensers, and physicians.16
Why does the difference between the two services matter?
The regulatory structure of naval hospitals, and the position of nurses in them, cannot simply be explained by the permanence of their institutions. Rather, they were part of a wider professionalization endeavor in the second half of the eighteenth century. The naval hospital hierarchy could only adequately function when everyone’s role in the hospital was clear. In the army, the role of nurses was less explicit and not carefully delineated. Yes, women working for the military provided valuable care, but it was not discussed as essential or specialized, nor were they given any authority in the military medical system.
These distinctions were, of course, important in the late eighteenth and early nineteenth centuries, particularly when considering the evolving nature of naval medicine and the comparatively stagnant nature of army medicine. However, the difference is also important for us today. When contemplating the pre-Nightingale period of nursing, it is often the military nurse discussed above that we remember, a woman seen even at the time as being replaceable, untrained, and unnecessary. Reconfiguring our view to also include the naval nurse — valued, crucial to hospital operation, and with a clearly defined role — complicates a familiar historical “before and after” picture.
- Instructions for the Regulation of Regimental Hospitals and the Concerns of the Sick (London: W. Clowes and Co., 1812), 12; “Admiralty Instructions to the Sick and Hurt Board 1741,” Office of the Commissioners of Sick and Wounded Seamen (Sick and Hurt Board) and successors: Out-Letters, TNA, ADM 98/103. Return to text.
- Instructions for the Regulation of Regimental Hospitals (1812), 12. Return to text.
- Regulations, to Regimental Surgeons, &c. for the Better Management of the Sick in the Regimental Hospitals (1799), 37. Return to text.
- Instructions to Regimental Surgeons, for Regulating the Concerns of the Sick and of The Hospital (London: Henry Reynell, 1803), Royal College of Surgeons Library, TRACTS A217(2), 4-5; Instructions to Regimental Surgeons for Regulating the Concerns of the Sick (1806), 21-22; Instructions for the Regulation of Regimental Hospitals (1812), 12; Catherine Kelly, War and the Militarization of British Army Medicine, 1793-1830 (London: Routledge, 2012), 93. Return to text.
- Instructions for the Regulation of Regimental Hospitals (1812), 12. Return to text.
- Robert Jackson, A System of Arrangement and Discipline, for the Medical Department of Armies (London: John Murray, 1805), 253. Return to text.
- J.G.V. Millingen, The Army Officer’s Manual Upon Active Service (London: Burgess and Hill, 1819), 112. Return to text.
- Regulations to Regimental Surgeons (1799), 37. Return to text.
- Martin Howard, Wellington’s Doctors: The British Army Medical Services in the Napoleonic Wars (Stroude, Gloucestershire: The History Press Ltd., 2008), 113. Return to text.
- “Robert Arbuthnot to William Fergusson,” April 2, 1810, William Fergusson Papers MS 1287, Yale University Library, Folder 3: 1809-1810; Millingen, 184-186, 189; “Regimental Hospital Preliminary Observations,” RAMC 210/3, Wellcome Library. Return to text.
- “Instructions, Precedents and Historical Notes Relating to the Sick and Hurt Board, Collected for the Board of Revision,” Volume 1, TNA, ADM 98/105, 437-440. Return to text.
- Ibid., 437. Return to text.
- Ibid., 438. Return to text.
- Ibid., 439. Return to text.
- Instructions for the Royal Naval Hospitals at Haslar & Plymouth (Philanthropic Society, St. George’s Fields, 1808), 201-208. Return to text.
- For example, see “Instructions for the Physicians of the Royal Naval Hospitals at Haslar & Plymouth,” Instructions for the Royal Naval Hospitals at Haslar & Plymouth, 49-51. Return to text.