The Emergence of the Occupation of District Nursing in Nineteenth Century England

The emergence of the occupation of district nursing in nineteenth century England by Elaine Denny, BSc, MA, RN, RHV Thesis submitted to the University of Nottingham for the degree of doctor of philosophy, May 1999 "Nursing, especially that most important of all its branches - nursing of the sick poor at home - is no amateur work" Florence Nightingale, 1865 ii Abstract This researchexamines the genesisof district nursingin England,and in particularexplores the way in which district nursingbecame a paid occupationover the courseof the nineteenthcentury. District nursingis definedas the careof the sick poor within their own homes,which is consistentwith a nineteenth,rather than a twentieth,century meaning. At the beginningof the centuryan occupationof district nursingdid not exist,yet by the end a formal occupationhad emerged,and some associationsof district nursingwere attemptingto createa profession which would attract educatedwomen. In order to explore the processesinvolved, empirical data were obtained from the records of nineteenth century district nursing associationsand organisations for their affiliation. These were interpreted and analysed within the theoretical framework of the sociology of work, occupation and professions, the concept of occupation being regarded as crucial in explaining the emergenceof district nursing. Since district nursing was an exclusively female occupation, particular emphasisis given to the gender division of labour. It was found that social changesassociated with urbanisation and the rise of capitalism in an age of enlightenment thinking, facilitated a move from an informal to a paid occupation. This was not, however, a linear progression, since philanthropic pursuit, particularly that of women, played an important role in the formation of most associationsand in constructing power relationships. The first associationswere Protestant Sisterhoodswhere iv subjective labour (Freidson 1978) dominated and controlled the work of paid nurses.By the end of the century most nurseswere part of the official economy (Freidson 1978), yet the involvement of philanthropic effort continued. Diversity among emerging associationshindered the development of a unified occupation with a discrete area of work and occupational identity, which in turn circumscribed the attempts of some organisations to create in district nursing a profession of educatedwomen. V Acknowledgements As with all such studies, the help of many people enabled me to carry out this research.Anne Witz encouragedme to register for a PhD, and acted as supervisor until a change of job took her to Scotland, after which Robert Dingwall and Julia Evetts had the unenviable task of taking on a project which was already underway. All three supported me, and made me look at things in different ways, which really grounded the researchtheoretically. Like many students I was better at interpreting the empirical data than setting it within a framework. The Faculty of Health and Community Care at the University of Central England (UCE) supported me financially, as did a grant from the Wellcome Trust, and I am grateful to both. Also at UCE, many colleaguesassisted with support and practical help. Mike Filby supported my application for study leave, and read and commented on chapters when I could not `seethe wood for the trees'. He often explained to me what I did not know I was thinking. SeanO'Sullivan covered teaching during my study leave, and David Cox read and made very helpful comments on an earlier draft of this thesis. Other colleagues have offered words of comfort over the School photocopier, or helped to relieve the stresswith an occasional `girls' night out'. Many librarians, from the smallest local studies centre to the most prestigious libraries in England, have made the task of researchinghistorical Vl sourceseasier, but Colin Harris at the BodleianLibrary in Oxford hasbeen a particularsource of advice. Throughout long hours at the word processor Tizzie (who has since unfortunately died) and Ben, provided constant canine companionship, and forced me into much neededbreaks, and walks on Welches' Meadow. As usual, it is partners who endure the long years and offer the most support, both practical by proof-reading, and emotional, during the roller coaster ups and downs of such a long piece of work. Love and gratitude, as always, to Clive. V11 INTRODUCTION The history of district nursing has suffered from the primacy given to hospital nursing, especially in the voluntary hospitals, with reforms and changesthat took place there being assumedto influence other forms of nursing by a ripple effect. Previous histories of district nursing which look beyond this approach have usually been chapters in more general histories of nursing (e.g. Dingwall et al 1988). The two best known works which concentrate solely on district nursing are Stocks (1960) and Baly (1987). Stocks took the year 1860 as her starting point for A hundred years of district nursing, although recognising that there had been previous district nursing ventures, and, like most traditional histories, concentrateson the work of William Rathbonel in Liverpool as being the beginning of district nursing in England. Although the first sentenceof the book asks when district nursing began, she does not question why it began, and rather takes the rationale and the process for granted. This is very much a Whig history, a chronological account of developmentsand milestones in the history of district nursing. Baly, by her own admission, was commissionedto write the history of the Queen's Nursing Institute in a specific way, as determined by the Institute. 2 The result is a celebration of the progress of district nursing. Neither work takes an explicit theoretical position, and neither questions the genesisof district nursing as a paid occupation. Both acknowledge that nursing 1 in the homehas always been carried out, andgive examplesfrom ancienttimes, but neitherexplores at a conceptuallevel the shift to a formal occupationwhich occurredover the courseof the nineteenthcentury. They also concentrateon the well known district nursingassociations, mainly in large cities, at the expenseof smallerones in towns and more rural areas. More critical histories have, however, been written about other occupations, and other branchesof nursing work (Rafferty 1996, Witz 1992). These have challengedtraditional nursing histories of gradual progress brought about by increasing knowledge and more discrimination in the employment of nurses, usually by using a case study approach. This has also been a feature of other work on the development of occupations (e.g. Macdonald 1995, Abbott 1988). General nursing, mental health nursing, health visiting inner alia all now have written histories based on critical analysisand contextualisation. This research aims to create for district nursing the type of analytical history that Witz (1992) produced on nurse registration, or Carpenter (1977) on managerialism;a sociological study of an occupational development. Even these critical histories, however, tend to concentrate on professionalisation. In this thesis the genesisand development of an occupation are seenas crucial. Apart from `filling a gap', my interest in the area is mainly professional. As a lecturer in health policy and in sociological analysesof nursing, I have long been aware of the focus of histories of medicine and nursing on the voluntary hospital as the inspiration and locale for changesin health care during the nineteenth century. Most people, however, would not have had entitlement to care in a voluntary hospital when sick, nor would they have readily entered a poor law infirmary. Nevertheless, social and economic changesengendered by 2 the industrial revolution and urbanisation would suggestthat caring for the sick or old was more difficult to incorporate into daily life than in pre-industrial times, especially for the poor. This, then, raisesthe question of what happened to the poor when sick? If they were not being cared for in large numbers in hospitals, then who was caring for them? As stated above, histories of nursing the sick at home showed that there were paid nurses, and that by the end of the nineteenth century a formal occupation existed. At least some of these nurses were attempting to professionalise.What is largely left unacknowledged, or assumedto be a steady progression towards professional status, is the process by which the occupation came into being and evolved. This is a central question in the history of district nursing, since professionalisation as such was a minority interest. In order to produce a more critical history of district nursing it is necessaryto make explicit, and to sociologically unpack, some of these `taken for granted' issues.In terms of the genesisof district nursing, it is not enough to describe what happened.We need to explore how and why it was that tasks that had previously been carried out informally came to be seenas more appropriate to a paid occupation. What was it about the social and economic conditions of the period that facilitated that change?Can sociological theories of occupation and professionalisation offer a useful explanation of the genesisand development of district nursing? To begin with, what do I mean by district nursing? The work carried out and the clientele have changed over time, but as this study is concerned mainly with the nineteenth century, I will use terms in a way in which I feel reflects their usage at the time. 3 Domiciliary nursing

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