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The Professionalisation of Mental Nursing in Great Britain, 1850-1 950

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The Professionalisation of Mental Nursing in Great Britain, 1850-1 950 THE PROFESSIONALISATION OF MENTAL NURSING IN GREAT BRITAIN, 1850-1 950 MICHAEL ARTON A Dissertation Submitted for the Degree of Doctor of Philosophy. History of Medicine, University College London, 1998 Summary The Professionalisation of Mental Nursing in Great Britain, 1850-1 950 This thesis takes the form of an investigation into the lack of progress towards the professionalisation of mental nurses dunng the period 1850 to 1950 and concentrates on their failure to become a professional sub-group within nursing. The proposal is put forward that their relative failure to advance was due to the fact that mental nurses were controlled and dominated by other more powerful health care groups with their own agendas. These were the asylum doctors in the (Royal) Medico-Psychological Association ((R)MPA), and the doctors and general trained nurses in the General Nursing Council (GNC). During the 1850s the (R)MPA's main concern was to raise the status of asylum doctors. The association aimed to achieve this by developing the care and treatment of the insane into another recognised speciality of medicine. To do this they needed to hospitalise the asylums, a process which would include transforming asylum attendants into qualified mental nurses. To this end a mental nursing textbook was published by the (R)MPA in 1885. This was followed by the inauguration of a national training scheme with certification for successful candidates. In order to advance the goal of hospitalisation, female nurses were introduced into male wards in many asylums. It was also asserted that the care of insane male patients was improved, a claim which led to conflicts with the trade unions, which were totally opposed to female nurses on male wards. The impact of unionisation of mental nurses will also be discussed in relationship to the struggle for professionalisation. Even when the Nurses' Registration Act 1919 was passed, mental nurses were caught in the middle of an internecine conflict over who controlled them: on one side was the GNC with its new supplementary register for mental nurses; on the other stood the (R)MPA, reluctant to give up their training and examination scheme under the conditions offered by the GNC. So a dual system of registration continued to exist until the introduction of the National Health Service in 1948. Even then mental nursing was still controlled by the general trained dominated GNC. CONTENTS Summary I Introduction 3 Chapter 1 Mental Nursing, 1850-1 950: An Under-Recorded History II Chapter 2 The Employment of Female Nurses on Male Wards in Asylums: An Aspect of Hospitalisation 57 Chapter 3 The 'Red Handbook' and the Training of Mental Nurses 98 Chapter 4 The Battle for Registration 164 Chapter 5 Association and Unionism 217 Conclusion 282 Acknowledgements 291 References 292 2 INTRODUCTION Within the practice of nursing, mental nursing has always been perceived as a separate and subordinate branch compared to general nursing, a secondary position which has prevented mental nurses from obtaining equal status with general nurses. This dissertation will examine the effects of this evaluation in respect, first, of the activities of the asylum doctors and then, later, of the leaders of the general nurses. However, the lesser status accorded to mental nurses was not only a historical phenomenon; it has also been observed in more recent times. In order to see how the happenings associated with the period under discussion have continued to influence more recent events, it is necessary to examine some of these developments. In May 1986, the successor to the General Nursing Council (GNC) I the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) (1) published its report, Project 2 000. A New Preparation For Practice, described as a radically new framework for preparation for practice (2). Originally this proposed new training, which all nurses were to undertake in order to be eligible for registration, was to consist of a common foundation programme (CFP) lasting two years, which would emphasise the promotion of health rather than a preoccupation with illness. The course would also enable the nurse to teach self help, promote independent living and respect the desires and values of the individual clients or patients. In the third and final year, the student would opt to follow one of the five main branches: mental illness, mental handicap, the child, midwifery and the adult. The latter, nursing adults, was the largest in terms of numbers of nurses involved and therefore these practitioners constitute the most influential and powerful group. Under this scheme there would be some specialisation allowed in the foundation course. However, those wishing to become mental nurses would be deemed fully qualified after just over one years specialised training and able to give safe and competent nursing care to the full range of psychiatric conditions. This scheme was considered an adequate replacement for a three-year specialised training in psychiatric nursing. "Such a profound educational change has been argued would threaten the independent professional integrity of mental health nurses in the United Kingdom." (3) 3 In 1986, Altschul accepted that the new branches were "not to be equated with the present parts of the register. She believes that Project 2 000 makes it possible for nurses to respond... better than the present training does." (4) However, in order for the new project to succeed most of what was included in the then current psychiatric training would have to be incorporated into the CFP. Needless to say, the UKCC was equally as dominated by generalists as its predecessor, the General Nursing Council. The implications of the implementation of Project 2000 by the UKCC will be discussed later in this introduction, with particular considerations given to the ramifications for mental nursing. The feedback from mental nurses regarding the UKCC proposals indicated that they would be willing to work within a branch framework: "three in four would prefer an eighteen month CFP and branch programme, or one year CFP and two year branch pattern." (5) A fair number wanted to change the branch name to mental health, rather than mental illness, a preference subsequently endorsed when the new branch title was adopted. From the late 1980s the English National Board for Nursing, Midwifery and Health Visiting (ENB) began to use the term Mental Health Nurse and Learning Disability Nurse for the previous terms Registered Mental Nurse and Registered Mental Handicap Nurse. However, the UKCC still referred to such nurses by the statutory terminology. Students who passed the DIpHE, or the degree course associated with Project 2000, were known as Registered Nurse (Mental Health) or Registered Nurse (Learning Disability). This new reorganisation of nursing led to the abolition of the supplementary registers, which originally came into existence as part of the Nurses' Registration Act, 1919. The subordination of the specialist branches of nursing is a recurring theme, as will be seen in this thesis, and has always been an aim of the general dominated profession. What makes the plight of psychiatric nurses peculiar is that despite the fact that their speciality contained large numbers of unionised male nurses, they did not become an effective pressure group able to lobby on their own behalf. Their apathy, which will be described in the thesis, was probably due to the fact that, throughout the period under study, mental nurses were controlled, firstly by the Royal Medico- Psychological Association (RMPA) and, later, by the GNC, and from 1979 the GNC's successor the UKCC. 4 Previous reports have echoed this theme of a general dominated profession, attempting to maintain control over all aspects of its practices. The first instance to be considered is that of the Committee on Nursing, under the chairmanship of Asa Briggs. Two mental trained nurse served on the Briggs Committee, Mr Ian Adams (June to July 1970) and fellow mental nurse, Mr R.F. Kempster (from June 1971). Its report, published in 1972, recommended that all entrants to nursing "receive a sound basic education in nursing, leading to an initial statutory qualification" (6), to be called the Certificate of Nursing Practice. Further, after the certificate stage, which would last two years, "there should be a mainstream post certificate course leading to registration," which would last one year (7). These courses would be followed and supplemented by a variety of post registration courses. The one-year post certificate registration course would include "three modules of education... the nursing students would study two modules in their field of choice and one balancing module." (8) The options provided were to be selected from general nursing, psychiatric nursing, community and mental handicap. Other specialist branches were ignored. Fever nursing was not included at all and paediatric nursing was only included "as one of ten options in a proposed new Higher Certificate after registration." (9) The final example of this post-Second World War trend to be examined is the report of a Special Committee on Nurse Education set up by the Royal College of Nursing (RCN) and chaired by Sir Harry Platt, the president of the International Federation of Surgical Colleges. Mental nursing was better represented on the Platt Committee. Two principal tutors from mental hospitals were included: Annie Altschul from Bethiem Royal and Maudsley Hospital in London and Reg Salisbury from Fulbourn Hospita' in Cambridgeshire, and John Greene, from Moorhaven Hospital in Devon, who was assistant chief male nurse representing training and service personnel. It was probably because of this strong mental nursing representation that the committee came to the conclusion that "the content of the basic syllabus.., be so different that preparation for the two parts of the register. Mental illness and mental handicap must continue as separate courses of study." (10) In contrast, paediatric nursing, despite the presence on the committee of G.M.
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