Susan McGann, Anne Crowther, Rona Dougall
Manchester, Manchester University Press, 2009, ISBN: 9780719077968; 384pp.; Price: £19.99
University of Ottawa
Date accessed: 2 May, 2015
Modern British nursing, based on formal training and skilled work, emerged within a tradition of religious sisterhoods (both Protestant and Catholic) and military reforms from the mid 18th century. It exerted significant influence over the development of nursing throughout the Anglo world following the tentacles of the British Empire – indeed often acting as an agent of empire, enabling the ‘settlement of colonies’ by providing health care for ‘settlers’ and eventually indigenous populations as well. Even in post-colonial worlds, British nursing left organizational and ideological legacies that continued to shape nurses and nursing work long after the achievement of national independence. Histories of British nursing, therefore, contribute importantly to diverse national and international contexts as well as diverse fields of inquiry such as gender history, labour history, histories of the professions, and health history broadly defined.
In addition, nurses comprise the largest group of health care workers and while there is a looming shortage of nurses globally, they are also perceived as the most expensive component of modern health care systems. American historian Susan Reverby portrays nurses as ‘ordered to care’ in a society that doesn’t value caring work, suggesting on-going discrepancies between perceived need for nurses and actual willingness to pay for their services.(1) In their institutional history, A Voice for Nurses: A History of the Royal College of Nursing, 1916–90, co-authors Susan McGann, Anne Crowther, and Rona Dougall offer a lens through which we can examine how similar tensions played out for the British nursing profession over a 74-year period.
The title, A Voice for Nurses, reflects struggles within the institutional life of the Royal College of Nursing (RCN). Initially the RCN set out to ‘to establish nursing as a profession, with a distinct body of knowledge and skills, for which all nurses should be fully trained’ (p. 1), with a pragmatic view to preventing ‘a post-war influx of semi-trained women into the profession (p. 36) – thereby embarking on a long involvement to control and regulate nursing education. But the RCN also had to deal with a second dilemma that was closely related, namely how ‘to improve the condition of nurses in the workplace’ (p. 2) as a key strategy toward professionalization. It was this focus that ultimately positioned the RCN as labour negotiator for British nurses and by 1977 saw its registration as a trade union, as it attempted to balance its institutional identity between ‘nursing’ knowledge and being the ‘voice of nurses’ in labour relations. The title also suggests that a history of the RCN is also about competing voices: who spoke for the collective body of British nurses over time, and whose voice would predominate in the long-standing struggles with the British Nurses Association, established by Ethel Bedford Fenwick in 1888, which continued to 1963 when the two organizations amalgamated.
In reviewing A Voice for Nurses one is struck by at least two challenges: the endurance of the organization and its broad reach that extended to include Scotland and Northern Ireland as well as England and Wales. Indeed the authors acknowledge these challenges as limitations, and call for historians to examine Scotland and Northern Ireland individually and in much more detail (p. 3). The authors identify their purposes as to describe the changing institutional framework of the RCN, and to offer explanations regarding how it survived and adjusted to changing circumstances over time (p. 3).
A Voice for Nurses is organized chronologically. Chapter one identifies key players in the debates over who would control both nursing and nurses, and the larger social and political contexts of the late 19th and early 20th centuries. The origins of class distinctions with nursing are clearly laid out and acknowledged as ‘a persistent divisive factor’ (p. 32) that continued to shape the life of the organization. The RCN capitalized on class distinctions as well as generosity from a ‘grateful nation’ during the First World War for early funding support, to establish itself firmly in the midst of two battles – for state registration of nurses and improvement of nurses’ working conditions (p. 37).
Chapters two and three characterize the period from the 1920s to the end of the Second World War as being one of consolidation, expansion, and struggle for influence. The authors position the organization as one among other non-feminist associations that engaged politically in specific areas ‘identified as within the natural areas of women’s expertise’ (p. 41) and ‘often working behind the scenes and enlisting male MPs to make their case politically’ (p. 42). As the RCN expanded in the form of local branches throughout the country, it also expanded membership to include public health and private duty nurses. Local branches were not only communication links but also windows into nurses’ working conditions – overlapping interests with trade unions seeking to move into this area. War again heightened anxieties about the supply of nurses for both civilian and military purposes, and put pressure on the organization regarding the educational preparation of nurses to meet these demands.
With the creation of the National Health Services in 1948, nurses became public employees; chapters four and five examine both their optimism for this transformation and their disappointments in the ability of the RCN to influence substantial changes. As nursing shortages grew and working conditions remained contentious, however, RCN membership fell and the organization faced challenges to its claim as the voice for nurses. Educational reforms remained a key strategy to address nursing shortages during the 1950s, now targeting both married women and men for recruitment. But apprenticeship training wherein student nurses continued to deliver the majority of hospital nursing care, still pitted their needs as learners with the hospitals’ needs for staffing – leading readers to chapter six, appropriately sub-titled a decade of discontent.
Nursing is always situated within the larger society and during the 1970s the British profession experienced a new type of nurse and a new level of militancy among nurses. The RCN responded with reorganization, new leadership, and renewed political activism that ultimately resulted in increased membership and support for rank-and-file nurses. According to the authors, these shifts pushed the organization into becoming a professional union as well. These developments are the focus of chapter seven where the authors argue that, ‘If the RCN had rejected unionism, and remained as a professional body, it would have lost its authority to speak for nurses in the workplace (p. 277)’. Other issues during this period concerned race and immigration as a strategy to meet the demand for nurses. The final chapter centers on the 1980s, suggesting that strong leadership and a decision to take nursing issues into the public forum resulted in substantial successes for the RCN as the voice for nurses.
The organization developed along two distinct lines of education and unionism, and continues to function in both today. It offered very practical courses for nurses at a time when they could find few other ways to increase their knowledge or advance their education. I was struck by the pervasive and persistent influence of class in shaping the organization, underlying deep divisions within the profession: different levels of care providers, how much education would be provided, to which levels, and where it would be provided (hospitals or educational facilities); and recurring debates on unionism among leaders and grassroots members.
A Voice for Nurses focuses entirely on one British nursing organization but the analysis carries importance for larger audiences beyond national boundaries, especially in demonstrating the significance of how health care is organized within larger sociopolitical systems. For example, from a Canadian perspective, our national nursing organizations function differently partially due to our federated national structure that mandates health care as the responsibility of the provinces. The Canadian Nurses’ Association (CNA) never became as involved in unionization movements as the RCN did although it did pay attention to labour and economic issues for nurses; and while the CNA offered an administration course for nurses for many years, it never became as involved in other forms of education as did the RCN.
There is a substantial body of scholarship on British nursing history although relatively few institutional histories on nursing organizations. Key examples and thematic areas include: Anne-Marie Rafferty and Susan McGann on nursing history and politics, Monica Baly on nursing and social change, Celia Davies on nursing and gender, Brian Abel-Smith and Christopher Maggs’ synthesis histories of the profession, and numerous histories of British military nursing.(2) With the exception of histories based on individual hospitals and training schools, institutional histories of nursing are sparse, partially due to increased interest among historians in social history, labour history, gender history, cultural and material history. Nonetheless institutional histories constitute important resources, especially in establishing chronology, key leadership personnel, and dominant issues an organization encounters over its lifetime. Like human biographies, the life of an organization is especially challenging to write during its lifetime – for which the authors are to be commended. A Voice for Nurses builds upon and complements earlier histories such as those of the General Nursing Council for England and Wales, the RCN (Rcn) in 1967, and the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (3)
- Susan Reverby, Ordered to Care: The Dilemma of American Nursing, 1850–1945 (New York, 1987).Back to (1)
- Anne Marie Rafferty, The Politics of Nursing Knowledge (London, 1996); Nursing History and the Politics of Welfare, ed. Anne Marie Rafferty, Jane Robinson, and Ruth Elkan (London and New York, 1997); Susan McGann, The Battle of the Nurses: A Study of Eight Women Who Influenced the Development of Professional Nursing, 1880–1930 (London, 1992); Monica Baly, Nursing and Social Change (3rd ed., London, 1995); Celia Davies, Gender and the Professional Predicament in Nursing (Buckingham, 1995); Brian Abel-Smith, A History of the Nursing Profession (London, 1960); Christopher J. Maggs, The Origins of General Nursing (London and Dover, 1983).Back to (2)
- Eve Bendall and Elizabeth Raybould, History of the General Nursing Council for England and Wales, 1919–69 (London, 1969); Gerald Bowman, The Lamp and the Book: The Story of the Rcn, 1916–1966 (London, 1967); and Celia Davies and Abigail Beach, Interpreting Professional Self-regulation: a History of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (London and New York, 2000).Back to (3)
We thank Cynthia Toman for her thoughtful review of our book, and for her instructive comparisons between the British experience of the development of nursing unions, and the very different North American pattern. The international development of nursing is a subject that requires much more detailed examination. The World Health Organisation has long argued that nurses, with varying degrees of training, rather than the more expensive medical staff, should be in the front line of world health campaigns, but national attitudes towards the social position of nurses differ widely, and have often impeded their usefulness in this role. Within national boundaries, the definition of a ‘nurse’ has encompassed many types of worker. As Professor Toman points out, our study emphasizes issues of social class and the problems it presented for nurse training, whereas in her own country, ethnicity has perhaps been a more potent issue. Her excellent work on Canadian military nurses in the Second World War, An Officer and a Lady (1), shows how these nurses, unlike British military nurses, were automatically accorded officer rank – but that women from the indigenous Canadian peoples were systematically excluded from the Canadian nursing schools – no possibility of officer rank for them.
We would like, however to reflect on one comment made by Professor Toman that ‘institutional histories of nursing are sparse, partially due to increased interest among historians in social history, labour history, gender history, cultural and material history’. This reads as though ‘institutional’ history is somehow different in kind from the other forms listed here (though this may not have been the writer’s intention). ‘Institutional’ histories have a mixed reputation in Britain, varying as they do in extreme cases between the glossy, photograph-heavy, coffee-table items beloved of marketing departments, and the densely detailed lists of past members, boardroom decisions and events that are of interest only to insiders (or rather, to the retired ones who have time to read them). Further, ‘institutional’ histories, unless backed by a subsidy from the institution, are not favoured by publishers, and academic funding bodies are deeply suspicious of them as insufficiently independent of the institution’s views. Before we began work on this book, we were given assurances by the Royal College of Nursing (RCN) that they would not seek to influence it in any way.
Our book is indeed the history of an institution, though the RCN is a rather unusual ‘institution’ with a membership of over 400,000, the great majority of whom are women, and, as Professor Toman confirms, one of our main aims was to show how the fortunes of this ‘institution’ were inextricably linked to the status and expectations of women in Britain during the 20th century. Histories of women in the labour movement have perforce taken their tone from Mary Macarthur’s dictum in 1908 that ‘while women are badly paid because they are unorganized, they may be unorganized because they are badly paid’. The RCN has been one of the largest and most successful organizers of women (and a smaller number of men) in the UK, though it was never beloved of the labour movement. We have tried to show why this was so. We hope that, rather than being an ‘institutional history’, our book contributes to gender history, to labour history, to the history of the professions, and, more widely, to social history.
- Cynthia Toman, An Officer and a Lady: Canadian Military Nursing and the Second World War (Vancouver, BC, 2007).Back to (1)