NURSESnursing and the hospital
wartime and professionalization
Over the course of the long nineteenth century, nursing in Europe evolved from a service performed predominantly by members of religious orders, servant-class women and men, and wives and mothers in their own homes, to a respectable career choice for middle-class women seeking to enter a modern health-care profession. The emergence of professional nursing was the direct product of several major developments in European history, including the blossoming of women's rights movements, the resurgence of religion, the rise of anticlerical politics, the rapid modernization of scientific medicine, and changing attitudes toward welfare and the poor. It is not surprising, therefore, that the history of nursing varies considerably from country to country. In Catholic countries like France, Spain, and Italy, nuns provided the majority of nursing care in hospitals until the last decades of the nineteenth century and, in some cases, into the twentieth century. Predominantly Protestant countries like England, Germany, and Sweden resorted earlier to the training of lay nurses, though religious women played an important in the development of nursing in those countries as well.
The transformation of nursing from a form of domestic or devotional service to professional occupation was in large part a consequence of changes in the institution of the hospital, especially during the second half of the nineteenth century. Until then, hospitals functioned primarily as asylums for the sick poor and the insane who had nowhere else to go. More affluent patients were cared for in their homes by servants or family members, at least until the last decades of the century. The indigent, by contrast, were brought—frequently unwillingly—to the hospitals, where they were crammed into unsanitary, overcrowded wards, often several to a bed; they could expect little if any actual medical treatment. Food was scarce and prospects for leaving the institutions alive were slim. Whatever care patients received came at the hands of members of religious nursing congregations or servant-class men and women, many of whom were former patients themselves.
While hospitals in Catholic countries relied heavily on orders like the Filles de la Charité de Saint-Vincent-de-Paul, the largest service-oriented congregation founded during the seventeenth-century, their counterparts in England and other Protestant countries were often forced to hire paupers to perform nursing duties. Long hours, unhealthy working conditions, and paltry wages discouraged all but the most desperate workers from seeking employment on the wards. Sairey Gamp, the crude, slovenly, incompetent, and ignorant nurse in Charles Dickens's novel Martin Chuzzlewit (1844) long stood as a symbol for unreformed lay nursing in England and elsewhere.
By the 1830s, the problem of caring for the poor had grown acute. Rapid industrialization and urbanization, first in England and within decades in Germany and France as well, brought legions of workers to cities and into workshops where harsh conditions made injury and illness likely. Poor-houses and workhouses filled to overcapacity; diseases like cholera and tuberculosis, which thrived in the overcrowded urban environment, brought renewed pressure on already inadequate health-care facilities.
Coinciding with the growing urban public health crisis was a powerful religious resurgence that swept the Continent, affecting all denominations. The numbers of active Catholic religious orders, especially for women, soared. Protestant denominations likewise turned their energies toward charitable activity. In the late 1830s, Pastor Theodore Fliedner (1800–1864) and his wife, Friederike Munster (1800–1842), established the German deaconess movement in a two hundred–bed hospital in Kaiserswerth. The deaconess movement encouraged devout Protestant women to serve as nurses in the hospital for five years after a lengthy probation period. All deaconesses received training from doctors and pharmacists. By the 1860s, the Kaiserswerth Hospital had trained approximately 1,600 deaconesses. Although work days were long (approximately sixteen hours) and the women received little pay, the establishment of the Deaconesses of Kaiserswerth was regarded by hospital reformers throughout Europe as a model for enlightened nursing practice. The influence of the deaconess movement was felt as far away as Russia and the United States. Among the many visitors who observed the nurses of Kaiserswerth Hospital were England's Elizabeth Fry (1780–1845), who subsequently founded the Institute of Nursing training facility in London in 1840, and Florence Nightingale (1820–1910), who spent three months there in 1851.
In England, the Anglican Church established several charitable orders for women including the Protestant Sisters of Charity and, in 1848, the Community of St. John's House, whose mission was explicitly to nurse the sick and poor. Members of the Community received two years of formal training before being admitted to serve in one of the hospitals run by the order.
The birth of the modern secular nursing profession is commonly associated with the endeavors of Florence Nightingale during the Crimean War (1854–1856). Faced with massive English casualties stemming from disease and infection, Secretary of War Sidney Herbert called on Nightingale, a family friend, to lead a delegation to nurse the sick and wounded at Scutari on the Bosphorus in Turkey. Gathering together a carefully screened group of thirty-eight nurses, including ten Catholic and eight Anglican religious sisters, Nightingale proceeded to institute a rigorous—critics often called it draconian—system of sanitation and care that eventually resulted in a reduction of the death rate at Scutari from 40 percent to 2 percent.
Nightingale's success quickly made her a heroine in England and throughout Europe. Her widely read Notes on Nursing (1859) argued that nursing was at once a vocation requiring extraordinary dedication and self-sacrifice and an honorable profession that demanded thorough training in both nursing theory and practice. In 1860 Nightingale opened a nursing school at St. Thomas Hospital, the beginning of what would soon be called the Nightingale System of nurse training. By the turn of the century, graduates of the program helped establish similar schools in Germany, Sweden, Denmark, the United States, Canada, Australia, India, and Ceylon.
In France the professionalization and secularization of nursing was caught up in the increasingly hostile politics of anticlericalism that dominated the early Third Republic. Although the Catholic nursing sisters continued to enjoy widespread popular support, many doctors and health officials in the closing decades of the century considered them premodern anachronisms in an era of enlightened, scientific medicine. Equally important, the sisters stood as reminders to anticlerical politicians of the continuing influence of the Catholic Church. Eager to secularize hospitals, the French government took the occasion of the disastrous casualty rates of the Franco-Prussian War (1870–1871) to urge municipalities to train secular nurses. Outside anticlerical Paris, however, the initiatives had limited effect. At the same time, ongoing political tensions with Britain limited the impact of Florence Nightingale's reforms in France. It was only in 1901 that the reformer and medical doctor Anna Hamilton opened the country's first "Nightingale-style" nursing school, a small, private institution in Bordeaux. Six years later, a similar school opened in Paris. On the eve of World War I, however, France still had only eight full-time secular professional nurse training schools.
But the professionalization of nursing did not always entail secularization. In early-twentieth-century Germany, more than half of the country's 75,000 nurses were religious: 26,000 were Roman Catholic sisters and 12,000 were Protestant deaconesses. The secular, professional German Nurses' Association had only 3,000 members. Similarly, the municipal government of Lyon, France's second-largest city, set up the nation's first full-time nursing school in 1899 not for ambitious, middle-class lay-women, but for the hundreds of religious sisters who staffed all the city's public hospitals. The city did not establish a lay nursing corps until the 1930s.
Despite the continuing presence of religiously based nursing, secular hospital, private, and visiting nursing made steady gains throughout most of Europe in the late nineteenth and early twentieth centuries. The rise of women's rights movements in many European countries and the simultaneous transformation of hospitals into medical research and therapeutic institutions accelerated the movement to professionalize nursing in the latter half of the nineteenth century. Alongside teaching, nursing became one of the few occupations considered acceptable for middle-class women. Although some doctors resisted rigorous theoretical training for nurses, fearing a challenge to their own professional authority, many more came to value the addition of knowledgeable assistants as long as they remained subordinate to the physicians.
The urgency of wartime medical care provided a continuing impetus to the development of professional nursing. The International Red Cross, founded by the Swiss Jean-Henri Dunant (1828–1910) at the Geneva Convention of 1864 in response to the horrors he had witnessed at the Battle of Solferino (1859), served as an institutional framework for the establishment of nurse training throughout the Continent. In many countries, Red Cross organizations were directly affiliated with the national government, giving nurses a nationalistic function that would peak during World War I when the Red Cross nurse became a popular symbol of feminine patriotic service.
By the twentieth century, nursing reform leaders, spurred on by the women's rights movement in which many of them participated, became increasingly eager to establish their professional autonomy, especially in relation to the newly powerful physicians organizations. In 1899 nurses from Great Britain, Ireland, the United States, Canada, New Zealand, Australia, Denmark, Holland, and the African Cape Colony founded the International Council of Nurses with the stated goals of encouraging self-government, establishing professional ethics, improving educational standards, and affirming minimal professional standards among participating countries. Ironically, only three countries (England, Germany, and the United States) met the ICN's standards for full national membership, though representatives of other countries were admitted as individuals.
The outbreak of World War I marked a major turning point in the development of nursing, as hundreds of thousands of volunteer and career nurses rushed to offer their services to the national cause. Never before had nurses received such public acclaim. But even before the accolades died down, some nursing leaders began to wonder if the romantic, heroic image of the wartime nurse would help or hinder the profession in the less glamorous theater of peacetime hospital wards.
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