A Study of Nursing Practices Used in the Management of Infection in Hospitals, 1929- 1948 A thesis submitted to the University of Manchester for the degree of Doctor of Philosophy in the Faculty of Medical and Human Sciences 2014 David Justham School of Nursing, Midwifery and Social Work 2 LIST OF CONTENTS Page List of Contents 2 Abstract 6 Declaration 7 Copyright Statement 8 List of Abbreviations 9 Acknowledgements 10 Preface 11 Chapter 1 Introduction and Method 12 1.1 The Context of the Study 12 1.2 Rationale for the Study 14 1.3 Research Question 20 1.4 Methods Used and Methodological Considerations 21 1.4.1 Oral History Method 22 1.4.2 Oral History and Memory 25 1.4.3 Sampling Strategy 30 1.4.4 Ethical Considerations 32 1.4.5 Recording Oral History 33 1.4.6 Transcribing Data 34 1.4.7 Analysis of Oral History Data 38 1.4.8 Archival Research 39 1.4.9 Use of Memoirs 41 1.5 Historiographical Considerations 41 1.5.1 Nursing History as a Separate Field of History 41 1.5.2 The Interpretation of Data to Inform History 43 1.6 Summary of Method 47 1.7 Structure of the Thesis 47 Chapter 2 Underpinning Concepts of Relevance to Infection in the 50 1930s and 1940s 2.1 Introduction 50 3 2.2 Miasma and Germ Theory 50 2.3 Ideas of Sanitation 54 2.4 Removing Dirt 58 2.5 Fear of Infection 61 2.6 Immunology 64 2.7 The Impact of Sulphonamides and Antibiotics 67 2.8 Development of Infection Control 72 2.9 Summary 75 Chapter 3 Issues in the History of Nursing 77 3.1 Introduction 77 3.2 The Hiddenness of Nursing Work 77 3.3 Status Issues in Nursing 82 3.4 The Context of Nursing Work 88 3.5 The Character of the Nurse 97 3.6 Leadership of Nurses 98 3.7 Education 100 3.8 Summary 105 Chapter 4 Care of Self – Health and Safety of the Nurse 106 4.1 Introduction 106 4.2 Death of Colleagues in Service 108 4.3 Becoming Ill through Work 109 4.4 Health and Safety at Work 111 4.5 Hand Hygiene 113 4.6 Strategies for Reducing the Risks of Acquiring Infection 117 4.7 The Spiritual Dimension 123 4.8 Summary 125 Chapter 5 Nurses and Environmental Cleaning 127 5.1 Introduction 127 5.2 ‘More like a domestic’ 127 5.3 Attitudes to Cleaning During the Study Period 134 4 5.4 Environmental Cleaning as a Nursing Duty 136 5.5 Status, Discipline and Retention Issues 141 5.6 Environmental Cleaning and Infection Risk 147 5.7 Summary 150 Chapter 6 Care of the Patient 151 6.1 Introduction 151 6.2 Background of Patients 152 6.3 Influence and Procedure in the Organisation of Nursing 155 Work 6.4 Personal Care Tasks 157 6.4.1 Admission Procedures 157 6.4.2 Pressure Area Care 160 6.4.3 ‘Toileting’ of Patients 165 6.5 Managing the Patient with an Infection 170 6.5.1 The Patient with Pneumonia 170 6.5.2 Nursing the Patient with a Life Threatening 175 Infection 6.6 Visitors 177 6.7 Discussion and Summary 178 Chapter 7 Technical Aspects of Care – Wound Care 182 7.1 Introduction 182 7.2 Wartime Challenges 184 7.3 The Dressing Round 186 7.4 Preparation of Equipment, Dressings and Bandages 191 7.5 Procedure for Redressing Wounds 196 7.6 Wound Infections and their Treatment 198 7.7 Summary 205 Chapter 8 Discussion 208 8.1 Introduction 208 8.2 Routinisation of Care Practices to meet Cleaning and 215 Hygiene Needs 8.3 The Hierarchy of Tasks and Care Practices 220 5 8.4 Vocation and Infection Control 226 8.5 The Beginning of the End of Sanitarian Nursing 228 8.6 Conclusion 232 Chapter 9 Conclusions 234 9.1 General Comments 234 9.2 Limitations of the Study 236 9.3 Further Research Questions Arising from the Study 240 9.3.1 The 1920s and Before 240 9.3.2 During the 1930s and 1940s 241 9.3.3 The 1950s and Beyond 242 9.4 Final Conclusions 242 Bibliography 250 Glossary 269 Appendices Appendix 1 Calculation of Sample Size 272 Appendix 2 Letter of Invitation to Potential Participants 274 Appendix 3 Consent Form 275 Appendix 4 Participant Information Sheet 276 Appendix 5 Clearance Note and Deposit Instructions 279 Appendix 6 Letter sent to the Local Press Appealing for 280 Participants Appendix 7 Brief Biography of Each Participant 281 Appendix 8 Guided Interview Schedule 284 Appendix 9 Example of an Interview Transcript 286 Appendix 10 Did Florence Nightingale Accept Germ Theory? 300 Word Count = 89,300 6 The University of Manchester David Justham Doctor of Philosophy A Study of Nursing Practices used in the Management of Infection in Hospitals, 1929-1948 2014 Abstract Before the availability of antibiotics minor infections could become life threatening. Nurses working in voluntary and public hospitals in Britain were exposed to such risks. This thesis uses both oral testimonies and published sources in order to examine their practices concerning the management of infection risks. The detail of nursing work in this period has been generally hidden in nursing histories of the 1930s and 1940s which have addressed mainly political, recruitment, educational, registration and status issues. Whilst these histories may comment about menial duties, and the culture and discipline in clinical areas, they lack detailed exploration of the day-to-day work of the nurse. This novel study contributes to redressing the balance by examining nursing practice between the discovery of penicillin in 1929 and its widespread availability in Britain in 1948. Data analysis, including the oral testimonies of nineteen former nurses who worked between 1929 and 1948, suggests that nursing practice during this period placed enormous emphasis on cleanliness and hygiene. It is argued that this was linked to sanitarianism which influenced nursing practice before its replacement by germ theory. Probationer nurses learnt their skills in managing infection risks to themselves and their patients in a disciplined and safe way. This was achieved through the exercise of strict routines and a hierarchy of tasks that provided a graduated exposure to the patient and infection risks. This thesis draws on debates in the literature about purity, vocation and status to explore, and add weight to this argument. The analysis also identifies that the introduction of sulphonamide drugs and antibiotics altered nursing practices in the management of both infection risks and patients with infection. Whilst the full effects of these changes are not examined in this thesis, it is argued that the significant impact of these drugs was such that the emphasis on cleaning and hygiene became diminished in importance and nursing had to redefine its role. It suggests that more prominence needs to be given to changes in clinical practice in the history of nursing. This study breaks new ground by suggesting the rigorous training of nurses in cleaning and hygiene tasks was needed in order to manage the infection risks faced by nurses before the availability of antibiotics. 7 DECLARATION I declare that no portion of the work referred to in the thesis has been submitted in support of an application for another degree or qualification of this or any other university or other institute of learning. 8 COPYRIGHT STATEMENT i. The author of this thesis (including any appendices and/or schedules to this thesis) owns certain copyright or related rights in it (the “Copyright”) and s/he has given The University of Manchester certain rights to use such Copyright, including for administrative purposes. ii. Copies of this thesis, either in full or in extracts and whether in hard or electronic copy, may be made only in accordance with the Copyright, Designs and Patents Act 1988 (as amended) and regulations issued under it or, where appropriate, in accordance with licensing agreements which the University has from time to time. This page must form part of any such copies made. iii. The ownership of certain Copyright, patents, designs, trade marks and other intellectual property (the “Intellectual Property”) and any reproductions of copyright works in the thesis, for example graphs and tables (“Reproductions”), which may be described in this thesis, may not be owned by the author and may be owned by third parties. Such Intellectual Property and Reproductions cannot and must not be made available for use without the prior written permission of the owner(s) of the relevant Intellectual Property and/or Reproductions. iv. Further information on the conditions under which disclosure, publication and commercialisation of this thesis, the Copyright and any Intellectual Property and/or Reproductions described in it may take place is available in the University IP Policy (see http://documents.manchester.ac.uk/DocuInfo.aspx?DocID=487), in any relevant Thesis restriction declarations deposited in the University Library, The University Library’s regulations (see http://www.manchester.ac.uk/library/aboutus/regulations) and in The University’s policy on Presentation of Theses 9 List of Abbreviations oC Unit of temperature on the Centrigrade scale cc Cubic Centimetre (equivalent to a millilitre) CNR Civil Nursing Reserve EUSOL Edinburgh University Solution of Lime oF Unit of temperature on the Fahrenheit scale FRS Fellow of the Royal Society GNC General Nursing Council for England and Wales GP General Practitioner HAI Hospital Acquired Infection M&B 693 Trade name for May and Baker product 693, a sulphapyridine MRC Medical Research Council NHI National Health Insurance NHS National Health Service POW Prisoner of War PTS Preliminary Training School RCN Royal College of Nursing SRN State Registered Nurse TB Tuberculosis UK United Kingdom USA United States of America VAD Voluntary Aid Detachment WWI World War I WWII World War II 10 Acknowledgements A number of organisations and individuals provided invaluable support, advice, guidance and encouragement during the seven years that this thesis has been in gestation.