Florence Nightingale is chiefly remembered for the reform of hospital nursing in the late nineteenth century, but scant attention has been paid to her involvement in the establishment and development of district nursing throughout England. Nightingale believed that the future of nursing lay in district nursing, with its dual aims of curative care and preventive education, yet historians of British nursing tend to concentrate on general nursing in the hospital setting because that is where training occurred.1 District nursing, if it is mentioned at all in such studies, is seen as only a footnote to the broader context of social history and philanthropy. The only official histories of district nursing were written by Mary Stocks and Monica Baly in 1960 and 1987, respectively,2and these two slim volumes remain the main sources on Queen Victoria's Jubilee Institute for Nurses (QVJl), the central body that standardized training and unified existing philanthropic schemes through its system of affiliation and inspection. Baly uses Stocks as her main secondary source, and although both books are factual and informative, their scope is limited by the fact that they were commissioned to celebrate milestones in the history of district nursing. They are, therefore, designed to be congratulatory and to emphasize positive progress over the years. They concentrate on the leading figures of the movement, not on the nurses themselves, and on details of politics and administration, not on the day-to-day duties and problems involved in nursing the sick poor in their own homes.
It is the aim of this article to help redress this imbalance in the historiography of nursing. By examining Nightingale's views and aims, I argue that the organizational structure of QVJI came closest of all branches of the profession to her vision of the future of nursing. The extent to which her theories were achieved in practice will be considered through the analysis of the Queen's Roll, which records the personal and career details of each Queen's nurse. In particular, I will show how the difficulties experienced in recruiting nurses for rural districts led to the introduction of a second grade of district nurse, the Village Nurse-Midwives. By analyzing the records of District Nursing Associations in Gloucestershire, where the rural branch of QVJI was founded, I discuss why QVJI failed to attract the class of recruits Nightingale envisaged and how, nevertheless, it became central to national health and welfare policies.
The Metropolitan Nursing Association
By the 1880s, the Nightingale reforms had clearly had an effect on hospital nursing in England, despite the entrenched views and professional jealousy of some doctors. The infirmary wards of workhouses had also been reformed and improved, and in rural areas almost 300 cottage hospitals had been established, which provided respite care for four to ten patients with a trained resident nurse and regular visits by a general practitioner.
However, Nightingale herself believed that 'the ultimate destination of all nursing is the nursing of the sick in their own homes.'3 As early as 1866, she had 'resolved to give herself to District Nursing.'4 At that time, Nightingale was offering advice and support to William Rathbone, a philanthropic merchant who was establishing a scheme of district nursing in his home town of Liverpool. At Nightingale's suggestion, in 1862, the Liverpool Training School and Home for Nurses was opened in connection with the Liverpool Royal Infirmary. Thus, the precedent was set that district nurses should be hospital trained, preferably under the Nightingale reformed system, as well as being specially trained in district work. By 1867, the city of Liverpool had been divided into eighteen districts, each with its own nurses.
In 1868, Rathbone was elected a Liberal MP and consequently spent part of each year in London. The personal contact this enabled him to make with Nightingale led to a lifelong friendship and mutual admiration. When, in 1874, Sir Edward Lechmere of the English branch of the Order of St. John of Jerusalem proposed that a system of district nursing should be set up in London, Rathbone and Nightingale were asked to help. Nightingale was at that time at the family home in Derbyshire. Her father had died in January, and she had temporarily returned to care for her mother, who was eighty-six, frail, and confused. Nightingale was therefore unable to personally organize the London scheme, but, as with the Liverpool system, she did everything that could be done from a distance. In 1874, she wrote a pamphlet, Suggestions for Improving the Nursing Service for the Sick Poor, and she recommended that a detailed survey be carried out on the district nursing needs and existing provision in London. For this task, she selected Florence Lees (later Mrs. Dacre Craven), an experienced nurse who had trained at the Nightingale School at St. Thomas' Hospital. Lees's survey covered twenty-two organizations, mainly religious and philandiropic bodies, which among them provided only 106 district nurses for the whole of London. Many of these nurses were only partially or barely trained at all; in the case of the Ranyard Bible Nurses, their original aim was to teach the Christian religion to the poor.
Mary Stocks describes Lees's subsequent report as one of the most important social surveys of the Victorian age,5 and as a result of her findings, the Metropolitan Nursing Association (MNA) was formed in 1875. The Duke of Westminster accepted the chairmanship and Lees was appointed superintendent general, responsible for recruiting and overseeing the trainees, who, after completing the standard one year's training as Lady Probationers at the Nightingale School, were to be trained specifically as district nurses. The MNA was based at 23 Bloomsbury Square, which provided an office for Lees and comfortable accommodations for five nurses. The first MNA trainees worked an eight-hour day, six hours in their district with the other two hours devoted to lectures or reading. They were allowed two hours leisure time in the evening and were guaranteed eight hours sleep a night. This rigorous training, which combined personal devotion with technical excellence, reflected Nightingale's belief that, to fulfill the grueling and responsible duties involved in caring for the sick poor in their own homes, 'a district nurse ... must be of a yet higher class and of a yet fuller training than a hospital nurse, because she has not the doctor always at hand; because she has no hospital appliances at hand at all; and because she has to take notes of the case for the doctor, who has no one but her to report to him. She is his staff of clinical clerks, dressers, and nurses.'6
In response, The Lancet expressed the opinion that district nurses would be better employed by 'the class who have some education, but who for the most part perform their own domestic work and keep no servants,' such as clerks and warehousemen, for whom 'the acceptance of help should not involve any loss of self-respect.'7
The Lancet also dismissed Nightingale's definition of the purpose of district nursing, which she envisaged as the dual aims of curative care and preventive education: 'Now, what is a district nurse to do? A nurse is, first, to nurse. secondly, to nurse the room as well as the patient - to put the room into nursing order; that is, to make the room such as a patient can recover in; to bring care and cleanliness into it, and to teach the inmates to keep up that care and cleanliness. Thirdly, to bring such sanitary defects as produce sickness and death ... to the notice of the public officer whom it concerns.'8
In The Lancet s view, such an approach would only cause further problems, as the poor 'resent the intrusion of strangers' and if 'a district nurse spies out the filthiness of a home, and makes a report which brings down inspectors ... [she] is likely to become a most unpopular personage.'9
Nightingale also believed that the district nurse must look for the means of mitigating suffering, even in incurable cases, and teach by example,
to sweep and dust away, to empty and wash out all the appalling dirt and foulness; to air and disinfect; tub the windows, sweep the fireplace, carry out and shake the bits of old sacking and carpet, and lay them down again; fetch fresh water and fill the kettle; wash the patient and the children, and make the bed And it requires a far higher stamp of woman ... thus to combine the servant with the teacher, and with the gentlewoman, ... [and] command the patient's confidence ... than almost any orher work.10
The Lancet countered by questioning the efficacy of encouraging the poor to remain in 'unwholesome dwellings' during sickness when they could be removed to a hospital. They suggested that the �20,000 that Nightingale hoped to raise for the MNA would be better spent building 'a hospital of one hundred beds' or improved housing for the poor rhan providing 'women who, in spite of training and an ability to take temperatures and scientific notes, might not always be a welcome addition to a small household.'11
However, The Lancet had always been critical of Nightingale's theories, particularly her belief that nurses should be educated ladies who could influence the behavior of the working classes through the power of social example as well as caring for them. The very purpose of district nursing, in Nightingale's opinion, was to separate the sick poor from each other rather than grouping them together in hospitals, and it appears that the public, the media, and the majority of the medical profession in London did not support The Lancet's contrary view. When Nightingale's letter to The Times was reprinted as a pamphlet, On Trained Nursing for the Sick Poor, it ran to two editions, and doctors in working-class areas acknowledged the value of the nurses' services.
The last quarter of the nineteenth century was in general a period of political and social reform. A plethora of wide-ranging legislation was passed in response to the growing awareness that the material conditions of the poor were as essential a part of paternalism as salvation of the soul. This combination of social and religious motives was manifest in the growing numbers and variety of urban visiting societies, whose volunteers could be found in hospitals, workhouses, prisons, and asylums, as well as in the homes of the poor. As social historian Frank Prochaska expresses it, 'Armed with the paraphernalia of their calling Bibles, tracts, blankets, food and coal tickets, and love - these foot-soldiers of the charitable army went from door to door to combat the evils of poverty, disease, and irreligion. In other words, they sought to reform family life through a moral and physical cleansing of the nation's homes.'12
Furthermore, the replacement of the Poor Law Board by the Local Government Board under the Act of 1871 brought public health into the same administrative department as poor relief. The subsequent series of acts during the 1870s, which consolidated previous attempts at sanitary reform, also saw the appointment of medical officers of health responsible for effecting national policies at the local level. This was a clear indication that the state should accept responsibility for the health of the people, including provision for the sick poor. In this context of national reform, the establishment and success of the MNA can be seen as reflecting the recognized need to improve the lives of the poor. Its work was confined to London, but Nightingale predicted that 'within a few years ... [it] will be a disgrace ... to any district... not to have a good District Nurse to nurse the sick poor at home.'13 The opportunity to translate her vision into reality came in 1887.
Queen Victoria's Jubilee Institute for Nurses
In that year, Queen Victoria celebrated her Golden Jubilee and the women of England were invited to make donations to a Jubilee Fund. Three million women subscribed a total of �82,000 and, after personal gifts of jewelry had been designed and executed by Carringtons of Regent Street and a statue of Prince Albert commissioned for Windsor Park, suggestions were invited for how the remaining �70,000 should be spent.
Florence Nightingale and her supporters saw the opportunity not only to place the MNA on a solid financial footing but also to extend its work throughout England. William Rathbone prepared a draft plan, which was then sent to Nightingale for her comments and input, particularly concerning the selection and training of district nurses. When the final plan was submitted for the Queen's consideration, it was chosen in preference to several other suggestions, such as supporting emigration. Queen Victoria was known to be sympathetic to nursing and she had followed Nightingale's career with interest. In addition, the Duke of Westminster, chairman of the MNA, was also chairman of the Jubilee Fund. These links were, without doubt, important in influencing the Queen's choice of how the Jubilee Fund should be spent, but Monica Baly believes that the establishment of a national district nursing scheme was also made possible by 'the changing social scene, the new awareness of the health needs of the community, together with the greater emancipation and better education of women at the end of the century, [which] brought it within the bounds of possibility.'14
On September 20, 1889, a Royal Charter was issued, formally establishing QVJI. The first Council of twenty-two members, selected by the Queen herself, included the Duke of Westminster, William Rathbone, Henry Bonham Carter, and the Reverend and Mrs. Craven (formerly Miss Lees), all of them known supporters of Nightingale and her methods. The degree of royal approval of and involvement in district nursing was further reflected by the inclusion on the Council of all rhree of Her Majesty's own daughters who were still resident in Britain at that time, Their Royal Highnesses the Princesses Christian, Louise, and Beatrice.
This Queen's Council accepted the MNA as the model for the new QVJI. Its training and syllabus were adopted, as was its most important and innovative precept, that its nurses should be supervised not by religious bodies or by philanthropic laity who knew litde or nothing of nursing but by superintendents and inspectors who were themselves both educated ladies and highly trained nurses. Existing urban district nursing associations, which conformed to the general principles of the foundation, were invited to apply for affiliation with QVJI. One of the first was Rathbone's own scheme in Liverpool, whose pioneering work in the 1860s had now, he said, spread 'far beyond anything that even the most sanguine of us could then foresee.'15
Rural areas were brought into the scheme by the affiliation in 1892 and eventual amalgamation in 1897 of the Rural Nursing Association (RNA), a national charity that had been founded in Gloucestershire in 1890 by a free-thinking intellectual, Elizabeth Malleson, and the altruistic Lucy Hicks-Beach, Countess St. Aldwyn.16 Small, independent rural nursing schemes set up by local philanthropic individuals already existed, but they were scattered all over England. As for their urban counterparts, the standard of their nurses' training varied, and some, such as the Cottage Benefit Nursing Association, founded by Miss Bertha Broadwood in 1883, provided nurses who lived in with their poor patients. The RNA was the first national rural district nursing organization, offering both nursing care and midwifery by trained visiting nurses, and by inviting existing isolated schemes to join, it established and maintained national standards of trained district nursing, controlled by a central body. By the time it was designated as QVJI's Rural District Branch, its nurses were working in twenty-five counties, and its impressive list of committee members and supporters included two duchesses, nine countesses, four viscountesses, and seventeen ladies. The organizational structure adopted by the RNA reflected the importance of the social hierarchy as it then existed, and it was incorporated into QVJI's own system when they amalgamated (see Figure 1).
At the local level, the manager of the District Nursing Association (DNA) was more often than not the local 'Lady Bountiful,' and the committee would consist of her daughters and worthy matrons such as the wives of the vicar, doctor, and headmaster. At the county level, the senior administrative posts of the County Nursing Association (CNA) would be filled by the ladies of the highest social rank and status; dius, in Gloucestershire, the county president was the Duchess of Beaufort and the vice president was the Countess St. Aldwyn. The county superintendent, who was herself under the supervision of QVJI inspectors, was to be a Queen's nurse (QN), and her appointment by the CNA required the approval of the Council of QVJI. The committee of each DNA was responsible for fund-raising, paying the nurse's salary, and providing suitable accommodation. In this way, the importance of the church and the social elite in rural areas was recognized and acknowledged; the prerogative and influence of the hierarchical society, with its accompanying overtones of noblesse oblige, remained operational; and the social fabric was not disturbed. At the same time, the quality of training, qualification, and subsequent day-to-day nursing was standardized on Nightingale lines by the requirement of annual reports from the DNAs and CNAs to the Council of QVJI and inspection of the nurses' work.
From its instigation, QVJI recommended that its nurses 'should all be duly approved women of excellent personal character, and of good education.'17 In its comment on diis announcement, The Times assumed that, 'bearing in mind what are the highest attributes of feminine character,' QVJI would 'provide a congenial vocation for numbers of refined and good women, and enable them to indulge their tenderest instincts unclogged by pecuniary considerations.... And some of the atmosphere of refinement which may be expected to surround a Queen's nurse will stay in the house when the nurse's mission is ended and she is gone.'18 In a letter to the newspaper, an unidentified doctor stressed that it was 'manifesdy essential' that such representatives of 'Her Majesty's benevolent desires' should be 'in all respects worthy,... in good health, of good character, of assured sobriety'; the treasurer of the North London Nursing Association added that 'this class of superior nurses' should be so 'worthy and self-sacrificing' that the idea of 'making broad her phylactery' would be 'generally distasteful' to them.19
From these comments it can be seen that, despite the general agreement that the aim of district nurses should be to improve the lives of the poor and to care for them, there was a clear difference of opinion concerning motivation. On the one hand, the media and public were calling for a pseudoreligious order that reflected the belief that philanthropy was the highest expression of women's 'natural' virtuous traits. On the other hand, Florence Nightingale envisaged paid professionals who were, nevertheless, inspired by a sense of calling. She believed that, as 'man cannot live by bread alone ... [so] woman does not live by wages alone.'20 She recognized the danger that district nursing could be seen by young women as the means 'to have a life of freedom, with an interesting employment, for a few years - to do as little as you can and amuse yourself as much as you can,' and she warned of the danger of district nurses responding to 'fashion ... [with] its consequent want of earnestness ... [and] the enthusiasm which every one ... must have in order to follow her calling properly.'21 She reiterated her definition of the purpose of district nursing by differentiating between nursing the sick ('to help the patient suffering from disease to live') and what she called 'health-nursing' ('to keep or put the constitution of the healdiy child or human being in such a state as to have no disease').22
By that time, Nightingale was also advocating the employment of healthmissioners. These were to be educated ladies who were not nurses but who would be trained to give lectures and instruction to the poor on sanitation and hygiene. She acknowledged that such women might prove difficult to find in sparsely populated areas, and she stressed that in isolated rural communities the district nurse 'also should be a health missioner as well as a sick-nurse.' By acting as 'missioners of health-at-home,' district nurses had the opportunity to address firsthand the social evils of 'dirt, drink, diet, damp, draughts, drains'; to achieve this, 'the nurse must have method, self-sacrifice, watchful activity, love of the work, devotion to duty, ... courage, ... the tenderness of the mother, the absence of the prig ... and never, never let the nurse forget that she must look for the fault of the nursing, as much as for the fault of the disease, in the symptoms of the patient.'23
Nightingale's views were formally embodied in A Guide to District Nurses and Home Nursing, a manual Mrs. Craven was asked to write for the use of QVJI nurses in 1889, and which Nightingale proofread. Nightingale's influence is clear, particularly where Craven stresses that a district nurse must be motivated by 'a real love for the poor, and a real desire to lessen the misery she may see among them Her aim must be not only to aid in curing disease and alleviating pain, but also through the illness of one member of a family to gain an influence for good so as to raise the whole family Wherever a district nurse enters, order and cleanliness should enter with her ... [and] every poor person should be as well and as tenderly nursed as if he were the highest in the land.'24
Training of Queen's Nurses
To achieve these high standards, QVJI required the following qualifications in 1890:
(a) Training at some approved general hospital or infirmary for not less than one year.
(b) Approved training in district nursing for not less than six months, including the nursing of mothers and their infants after childbirth.
(c) Nurses in country districts must have at least three months' approved training in midwifery.25
The distinction between clauses (b) and (c) was an important one. QNs working in towns were not expected to undertake midwifery cases, but they could attend to a mother and baby after birth if a doctor decided they needed nursing attention as opposed to routine postnatal care. QNs in rural areas were expected to be qualified for midwifery cases but only as a precautionary measure; it was stressed that 'the duties of the midwife, as distinguished from a nurse, are not to be undertaken, except in cases of emergency.' However, midwifery formed an important part of the RNA's work, and under the terms of its Constitution as the Rural District Branch, QVJI's Council compromised between what it considered desirable and what was practically possible in remote areas: 'The services of the midwives are intended for those who cannot afford doctors' fees.' Because this applied to the majority of poor rural families, midwifery was clearly established as an integral part of a rural district nurse's duties.
A Medical & Sanitary Subcommittee was formed, whose members included Craven, and the syllabus they devised ensured that the subjects not taught to nurses in hospitals figured prominendy in the training of QNs. The syllabus reflected Nightingale's dual aims of curative care and preventive education by including sanitary reform, teaching health matters, ventilation, drainage, water supply, diets for the healthy and the sick, the feeding of infants, infectious diseases, monthly nursing of lying-in women, and the care of newborn infants. All these subjects had to be covered in the six months' training course, along with practical work, and were tested by a three-hour written examination in which six questions had to be answered.
The additional midwifery training was equally demanding. Under the Midwives Act of 1902, the widely recognized and accepted examination of the London Obstetrical Society was replaced by a similar examination conducted by the newly formed Central Midwives Board and held four times a year. The training period for midwives was set at only three months, and the examination was pardy written and partly oral. The written examination, like the paper for QNs, consisted of six questions to be completed in three hours, while the oral examination was of fifteen minutes' duration.
Social historian Jane Lewis states that the initial training period was set so short for fear of creating a shortage, and that the midwives themselves pressed for a longer period of training, believing that it would improve their professional status and make the work more popular among 'a superior class of women.' In 1916, the training period for untrained women was doubled to six months, but it remained diree months for trained nurses. This coincided with World War I and, consequently, a shortage of male doctors on the home front, many of them having volunteered for duty in the Army Medical Corps.
The resulting increase in births attended by midwives continued after 1918, particularly in rural districts, and reports on maternal mortality, produced by Dame Janet Campbell of the Ministry of Health in 1923 and 1927, 'emphasised the particularly fine record of the QVJI midwives, who served all of England and Wales with the exception of Wiltshire, Essex and Northumberland, attending 80,147 cases (10%) in 1924. Where they worked... the maternal mortality rate was half the national rate.'26 This statistic does not differentiate between home deliveries by a midwife alone and difficult cases where a doctor was called in to assist. However, the diorough and demanding training of QVJI nurses ensured that they recognized such difficult cases and knew when to send for medical assistance, which fact alone could be instrumental in saving both mother and child.
In 1924, the training period for midwives was again doubled, to twelve months for untrained women and six months for trained nurses. Meanwhile, QVJI's district training course for QNs remained at its original six months, whde the prior qualification of not less than one year's experience in a general hospital or infirmary in 1890 was increased in 1906 to 'not less than diree years' training in approved hospitals or infirmaries.'27 Thus, QVJI specified a uniform length of training and standard of qualifications for all its nurses starting in 1890, twelve years before the Midwives Act and almost diirty years before the introduction of the Registration Act. In fact, the Queen's Roll was established at the very time that Florence Nightingale was battling with the Royal British Nurses' Association (RBNA) over the attempt of the latter to provide a register of qualified nurses.
Founded and led by the formidable Mrs. Ethel Bedwick Fenwick, who had been made Matron of St. Bartholomew's Hospital, London, at the age of twentyfour, the RBNA was agitating for a standard certificate of proficiency that would be awarded by an independent body of examiners rather than by the individual hospital at which a nurse had trained. The nurse would then be entided to have her name placed on a national register of nurses. Nightingale believed diat, even after thirty years of reform, nursing was still too unorganized and divergent for an official national register, and she used her considerable influence to ensure the charter granted to the RBNA in 1893 omitted the word 'register' and conferred only the right to the 'maintenance of a list of persons who may have applied to have their names entered thereon as nurses.'28 In her definitive biography, Cecil Woodham-Smidi stresses that Nightingale
was not necessarily against registration, but she was passionately opposed to the kind of registration proposed. The qualifying of a nurse by examination only took no account of the character training which she held to be as important as the acquisition of technical skill.... Not in het opinion would the register as proposed protect the public. The fact that a nurse's name was on it would only mean that at a certain date she had satisfied the examiners in certain tests; it would tell nothing of her subsequent record. If a register were to be useful it should be kept up to date, and include a description of each nurse's character.29
Such a scheme was never achieved for general nurses, but from its inception, QVJI, with its national system of supervision and regular inspections, did ensure that, once qualified, its nurses continued to maintain standards, and its centrally held records provided exacdy the type of comments that Nightingale deemed essential, covering character and conduct as well as work. The Queen's Roll records the personal and career details of each QN, including date of birth, marital status, religious denomination, education, fadier's occupation, own previous occupation, hospital training and nursing experience, district training, certificates and badges, and reports on posts held. These unique records offer a fascinating insight into the lives of the QNs, and also offer the opportunity to consider the extent to which QVJI's aims were met in practice.
The Queen's Roll
As we have seen, Florence Nightingale believed that, to fulfill her dual aims of curative care and preventive education, a district nurse needed to be an educated lady. Craven boasted that some of the earliest applicants to train with the MNA had been presented at court as debutantes. However, surviving records of paternal occupations among the 539 nurses listed on the Queen's Roll in 1896 include several clergymen, an Oxford professor, a solicitor, a bank manager, two army officers, and a farmer, which suggests a predominantly middle-class background. Among the earliest QNs, Alpha Fenton, who qualified in 1892, was the daughter of an auctioneer and listed her own previous occupation as 'housekeeper to brothers.' The records of Leah Garratt, who qualified in 1890, do not include her father's occupation, but Leah remained 'at home' until she began her hospital training at Worcester in 1886 at the age of twenty-one, which, again, suggests a comfortable background.30
This trend continued in the early years of the twentieth century. Of a sample of twelve nurses who qualified as QNs between 1902 and 1908, only two (17 percent) record a previous occupation: Alexina Cowee and Ann Newdick, bodi of whom had been children's nurses and were the daughters of farmers. The other ten (83 percent) either give no previous occupation or are listed as 'at home.' Where fadier's occupation is recorded, diese include a printer, a merchant, and two clergymen. The father of Olive Goddard was 'in Her Late Majesty's consular service in China,' whde Margaret Powell, daughter of an army officer, was recorded as being 'refined and nice in her ideas though not a lady by birth.'31
By 1913, one of the items for discussion at a Conference of Superintendents was, 'It seems that the type of woman now taking up district work is not what it used to be, judging from those applying Can anything be done to make diis work more attractive to the woman wishing to devote herself to work amongst the sick poor?'32 Any points raised or conclusions reached were not recorded, but, among QNs who qualified between 1910 and 1917,43 percent had worked prior to hospital training, their occupations including a cashier and a flosser. Paternal occupations included an engineer, two bootmakers, a florist, and a grocer, which suggests a more upper working-class than lower middle-class background.33
When the question of the nurses' social background was discussed again in 1922, it was 'thought that nurses did not apply as they formerly did because there were now many more professions open to women, district work was hard, the nurses objected to further training after the diree years in hospital, ... the diought of another examination and the binding of a year's agreement were deterrents, as also was the knowledge that there was no pension after the term of service.'34
Among QNs who qualified between 1919 and 1925, paternal occupations now included two engineers, a postman, and a master joiner, and 67 percent of the nurses had previously worked, their occupations including shop assistants and a clerk. Social background alone is, of course, no definite indicator of intelligence and practical nursing ability. Susie Bayliss, a former serving maid, was described as 'a most capable, practical nurse,' and she rose to become assistant superintendent in Portsmouth from 1930 to 1937.35
All candidates for training as QNs had to have already qualified as hospital nurses, although before the Registration Act, the length and quality of their training varied. Nevertheless, the requirement of this prior qualification, together with the breadth and depth of technical and theoretical knowledge demanded by the district training, assumed a certain level of ability and literacy. In fact, the Queen's Roll suggests that some candidates struggled to achieve the required standard. The examination paper for QNs carried sixty marks, and although the minimum pass mark and pass rate are not known, where examination results are recorded, comments on marks below 75 percent cite educational difficulties, particularly for working-class candidates (see Table 1). Beatrice Price, a grocer's daughter, was noted throughout her career to be 'not a good record keeper' whose 'ante-natal records suggest paperwork is rather difficult.'36
Once qualified, a QN would be sent for one year to a post arranged by QVJI, after which she was free to apply for a vacancy of her choice. In towns, a central home was provided because Nightingale believed that the morale, health, and reputation of the district nurses would suffer if they did not enjoy the same safe respectability and warm supportive companionship that her vision of the ideal hospital nurses' home would provide. However, in many hospitals, as feminist historian Martha Vicinus expresses it, 'descriptions of life in the nurses' home sound like a combination of boot camp and boarding school... with stringent and often unnecessary regulations enforced by ancient and unrelenting battle-axes Meals were remembered as dreary and hasty affairs, without relaxation of discipline... The elaborate system of times off and on made it difficult to keep the dining room clean and the food fresh... Litde variety and much starch depressed everyone.'37
It is perhaps not difficult to imagine that an urban district nurses' home, located within the community the nurses served, with fewer staff than a hospital, would have created a more homelike, intimate, and supportive atmosphere. At Stroud in Gloucestershire, three nurses took up residence at 'The Home' in 1895, under the superintendence of a Miss Blackwell. By 1898, their number had increased to six, and patients were attended not only in Stroud itself but also in nine surrounding villages. The Annual Reports of the Stroud DNA regularly acknowledge gifts of flowers, fruit, and vegetables that had been 'gratefully received at the Nurses' Home,' which suggests a cheerful ambience and healthy diet.38 Similarly, between fifteen and twenty nurses shared the Victoria Home in Cheltenham from 1905 to 1925, and thanks were regularly expressed 'to Mr Beadnell, who tunes the piano without charge,' to 'Messrs Webb Bros [who] have very generously supplied the Home with firewood, free of cost,' and to 'Messrs Jack & Co [who] attend to the hall clock free of charge.'39 The house was supplied with a hot-water system for which 'the pipes were passed through a large cupboard, and diis gives a place for drying the nurses' cloaks in wet weather,' while 'a well-built weather-proof house in the garden' was installed 'which could accommodate sixteen bicycles.' QVJI Inspectors concluded that 'die Home was comfortable, the food was excellent and abundant ... and, though hard work is done, the Staff and the pupils are happy.' When Caroline Coaling was superintendent of the nurses' home in Southampton from 1910 to 1921,... she was reported to be 'an excellent housekeeper [who] makes her nurses happy and comfortable.'40 By 1922, it was reported that 'in England and Wales there were 17 Homes with staffs above 10 nurses, 123 with staffs of from 4 to 10,49 with staffs of 3 [and] 152 Districts with 2 nurses.'41
Such communal arrangements were only possible in urban areas, and in rural areas the majority of district nurses lived alone. They were provided either with board and lodging in two furnished rooms, with attendance, fuel, and light, or with a rented cottage. Although some nurses enjoyed the independence, responsibility, and sense of achievement such a post could offer, others found that they had exchanged a restrictive hospital life for one of isolation, and in 1922, the Queen's Nurses'Magazine noted that 'the loneliness of a single district was very trying.'42
Whether employed in an urban or a rural district, each nurse worked alone, and it is clear from the records that many were conscious of the importance of their role in the community. Although the certificate of the London Obstetrical Society (LOS) was still recognized and its possession automatically admitted a nurse to the new Roll of Midwives opened by the Central Midwives Board (CMB) in October 1903, some of the earliest QNs also took the new examination. Alpha Fenton, who had passed the LOS Certificate in 1892, also gained the CMB Certificate in 1904. Similarly, Fanny Mellor, who passed the LOS Certificate in February 1903, only eight months before the Midwives Roll opened, took the CMB Certificate a year later, while Helen Moore passed the LOS Certificate in July 1903 and took the CMB Certificate just six months later.43 The fact that an additional certificate was not compulsory for these nurses, who were already practicing QNs, suggests that they were anxious to be seen as up-to-date professionals.
However, the work of some QNs gave cause for concern. Elizabeth Williams, who qualified as a QN in January 1907, left the Cheltenham DNA in July of the same year, after her first inspection found that it was 'not desirable that Nurse Williams should be recommended again.'44 Hilda Boston was noted in 1924 to be 'needing supervision' as her work was 'rather slipshod.' Eventually, she resigned from QVJI, when she was 'cited to appear before CMB,' her final inspection having found her to be 'apt to neglect details. Very impulsive and has a difficult manner.'45 The Webb sisters were recognized as being kind and hardworking, and were liked by their patients, but Florence was considered 'unsuitable for Public Health Work' and Lilian was 'an unsatisfactory worker who needs strict supervision. Entirely unsuited for district midwifery and Child Welfare work.' They served together as district nurses for only two years, at Cinderford in Gloucestershire from 1924 to 1926, before both resigned to take up private nursing.46
Improvements were acknowledged as a nurse's career progressed and she became more experienced and competent. Margaret Powell was 'not up to Queen's standard' in 1906, but by the time she resigned from QVJI during World War I to take up a post as lady superintendent in a munitions factory, she was reported to be 'an excellent School Nurse and a willing worker.'47 Kate Hastings was reported to be 'not competent to teach' at Plaistow in 1908, but when she resigned her post in Manchester to be married in 1912, her final inspection found her to be 'a very capable nurse with a good educational influence.'48
Individual clashes of personality, regional traits, and a lack of knowledge of local customs could also cause problems. In such cases, comments could be blunt and unequivocal. Adeline Sproat left her first post in Northampton in 1908 because she 'failed to work amicably with Supt,' and in her next post in St. Helens, she was noted to have 'not a happy disposition.'49 Caroline Lee was 'hot-tempered, ... self-opinionated and impatient of control,' while Susannah Jenkins was 'not easy to get on with in the Home Quick-tempered, ... very difficult and over-bearing in manner.'50 Mildred Griffiths was noted to be 'inexperienced in country work' in 1911, with a 'somewhat irritating and self-opinionated manner.'51 Jessie Douglas was also 'inexperienced in dealing with country people' when she took up her first post as a QN at Treverbyn in 1911, and while she was working at Godierington in Gloucestershire from 1914 to 1915, her reports read 'manner brusque, temperament lethargic' and 'not very enthusiastic or sympathetic.' However, when she returned to her native Scodand, she was reported to be 'careful, interested and much-liked.'52 During twenty years as a QN in urban posts in the north of England, Cadierine Phillips was regarded as 'a clever, capable nurse,' 'a very careful maternity nurse and a pleasant woman,' and 'kind, willing to please.' Yet, when she briefly worked at Nailsworth DNA in rural Gloucestershire in 1923, she was described by the honorary secretary as 'untidy and unprincipled' and by the county superintendent as 'unreliable and of a difficult temperament.'53 Rose Paling was 'inclined to talk too much' and 'resenting authority,' while Beatrice Price was 'somewhat secretive in manner.'54
At the other extreme, an outstanding few progressed to senior positions within QVJI. Bessie Taylor was recognized during her district training to be 'suitable for responsible post,' and by 1920, she was county superintendent of the West Riding of Yorkshire, where she proved 'equal to the work expected of her.'55 Lena Milford enjoyed an exemplary caretfr in Gloucestershire as nurse at Coin St. Aldwyn, assistant county superintendent, and, from 1917 to 1946, 'a wise, progressive, hard-working and highly esteemed' county superintendent.56 With her forceful personality, Caroline Lee progressed to being county superintendent in Kent, Derbyshire, and Northamptonshire; she ended her career as a recruitment officer from 1930 to 1936, presenting 'Queen's Institute Propaganda in Hospitals,' where she was considered to be 'an excellent speaker.'57
The few district nurses who enjoyed such distinguished careers and rose to high office within QVJI could be said to be as unrepresentative and atypical a minority as were the negative examples. The sUent majority of district nurses emerge from the Queen's Roll as unassuming and industrious workers who approached their duties with the loyalty and fortitude Florence Nightingale envisaged.
Lewis believes that midwifery and nursing both became middle-class preserves as the twentiedi century progressed.58 However, the evidence provided by the Queen's Roll suggests that district nursing, which combined midwifery and nursing, particularly in rural areas, increasingly attracted young women from the upper working classes. Furthermore, the statistic Lewis quotes, of 10 percent home deliveries in 1924, refers to all QVJI nurses; it does not differentiate between QNs and the second grade of district nurse that was introduced in rural areas.
Village Nurse-Midwives
The anomaly of rural district nursing lay in the fact that, in the areas where the nurses were most needed, the poor patients could least afford to subscribe to local funds, and many DNAs found themselves unable to pay the wage for a QN. In addition, many of the nurses were reluctant to work in isolated rural areas and found the responsibility of midwifery daunting. In an attempt to solve these problems, under the Conditions of Affiliation for County Nursing Associations, first issued in 1897 and revised in 1901, the Council of QVJI sanctioned 'the employment of Village Nurses in rural districts where it is impossible to support a Queen's Nurse and the population of the district does not as a rule exceed 3.000.'59 These village nurse-midwives (VNMs), as they soon became known, were not hospital-trained nurses. They were local working-class women whose district and midwifery training was paid for by the CNA, in return for which they contracted to work in the county for a minimum of three years.
The introduction of this second grade of district nurse caused widespread resentment among the QNs, who regarded them as professionally inferior due to their lack of hospital experience. These feelings were made clear in an unattributed article in the Queen's Nurses' Magazine in 1910: 'The work of County Nursing Associations is not very cordially accepted by many Queen's Nurses. There is a prevalent uneasy idea that the Queen's Institute in recognising these Associations and their 'Village Nurses' has departed from its original standard, and approves that much-scorned individual, the 'half-trained nurse'.' The article reminded its readers that the supervision of VNMs by the county superintendent 'had helped in a marked degree to raise the general standard of work' and reassured them that in rural areas, 'where it is not possible to provide work and funds to justify the employment of a Queen's Nurse, the village nurse is a valuable factor, filling a real need, and under wise supervision taking her share in building up the health of the community.'60
Despite the official support for VNMs, professional jealousy persisted among the district nurses. When Margaret Powell became an assistant superintendent to the Gloucestershire CNA, it was noted that she was 'not always tactful in dealing with Village Nurses.'61 At a Conference of Queen's superintendents in 1913, 'a lack of sisterly kindness on the part of some Queen's Nurses to their less trained sisters' was noted, and among the questions discussed was 'Can we remove the spirit of opposition that exists in our midst against the employment of inferior trained nurses by County Associations?' Unfortunately, neither the points raised in the discussion nor the conclusion reached are recorded, but the fact that the matter was discussed at 'one of the largest gatherings in the history of the association' illustrates both the extent of the problem and the seriousness with which it was regarded by the most senior members of QVJI.62
As a result of these concerns, over the years the length and content of training for VNMs were regularly reviewed and increased. In Gloucestershire, the first report of the CNA, dated 1905, specified that the qualifications for VNMs should be 'Twelve months' - or in no case under six mondis' - training at some approved training place, with Midwifery instruction and certificate.' The following year, it was stressed that the training of VNMs 'forms one of the most important duties of the Association,' but that this work had been 'a good deal handicapped by lack of funds and the difficulty of finding suitable women to train as Village Nurses.'63 In fact, in April 1906, when the subcommittee responsible for selecting trainees 'met at the Superintendent's house to interview candidates for training as Village Nurses, only one kept her appointment and she was not considered suitable.'64 Only two VNMs had completed their training that year and been appointed to DNAs in the county, Mathilda Brown, who 'had started work at Sapperton & Coates and was much liked,' and Jennie Chambers, who was reported to be 'doing well at Whitminster.' One candidate, Rose Gardiner, had broken down in health after three months training and had been sent home, and Miss Kendall, who had been interviewed and approved, regretted that 'owing to private reasons' she could not accept the offer of training. A further two women, Mrs. Shaw and Letitia Burden, were in the course of training, while two candidates, Mrs. Roberts and Mrs. Till, had bodi twice failed to pass the CMB examination.
In 1906, QVJI increased the minimum training period for VNMs from six to nine months, and in 1909, a QVJI inspector informed the Gloucestershire CNA in her annual report of 'the desirability of a twelve months' training for the County Nurses, as is now generally the rule,' and as was laid down in the county's own scheme.65 Implementation of these changes increased the cost of training for each nurse, an expense that had to be met from already stretched county funds, raised from grants, donations, subscriptions, and DNA affiliation fees, supplemented by parish collections, plant and garden sales, Flag days, and bazaars.
Between 1905 and 1919, the majority of Gloucestershire VNMs received their training at the District Nurses' Home at Plaistow in London, with the occasional placement of one or two trainees at the Victoria Home, Cheltenham, Kingswood in Bristol, or Tipton in the West Midlands. During that period, an average of six VNMs was trained each year. From 1919, Kingswood District Nurses' Home became the main training center for the county, although one or two trainees continued to be placed in Cheltenham. This arrangement 'proved very satisfactory - the Home is very comfortable, and the pupils are thoroughly well trained and cared for in every way.'
In 1907, the ideal VNM was described as a 'young married woman who would be able to undertake the work in her own and neighbouring parishes.'66 However, the Gloucestershire CNA reports regularly express regret and concern at the great scarcity of suitable candidates for training. Unfortunately, few personal details are recorded of the VNM applicants, but from the available data it can be seen that the average age of candidates accepted for training was 31.3 years (see Table 2). When a year is added for training, the average age of qualifying as a VNM becomes 32.3 years. Of the seven applicants for whom marital status was recorded, one was single, one was separated, two were married, and diree were widows. A further twenty-one applicants (not all of whom were accepted) are referred to in the CNA Minutes as 'Mrs.,' but whether they were married or widowed is not recorded.
Among the earliest applicants to be rejected was Mrs. Lucas, who 'was 60 with no education and it was decided that it was impossible to help her,' while Mrs. Edith Mills, aged forty-four, was considered 'too old' and Mrs. PhUlips 'was quite of the cottage class.'67 Alice Brown was rejected in 1909, 'as her medical certificate stated that her heart was not quite normal'; the following year, it was decided not to train Miss A. Hathaway, 'as the doctor did not consider she was strong enough for district work'; and in 1911, Lizzie Hardwick was rejected 'as her medical certificate was not satisfactory.' Several women were classified as 'unsatisfactory' or 'not suitable' without any specific reason being given, including Mrs. Baxter, a widow from Cheltenham with six years experience as an unqualified midwife, and Mrs. Trigg, who had been approved in 1910, but 'as further information had been received ... it had been decided not to train [her].'
Among those who were approved for training, Minnie Bishop 'wrote to say she did not wish to be trained as she could not bind herself to work in the County for three years,' Bessie Mourton and Mathilda Wardle both fell ill and could not take up their training places, while Mrs. Loveday and Mrs. Laver both decided not to be trained. Nurse Thompson did complete her training in 1907, but her work at St. Briavels 'was reported not to be very satisfactory.' It was decided that the county superintendent 'should talk to her and that she should be given another chance.' She was transferred to a new district in January 1908, but after just two months in her new post, the secretary 'wrote saying she had given Nurse Thompson notice as her work was not satisfactory. It was decided not to give her further employment.' Fanny Wickenden was sent for training in August 1909, but she 'did not appear equal to the demands made on her during the training and was recalled' in December.
In that same year, another Gloucestershire trainee, Mrs. Dawe, failed the CMB examination. The CNA Committee had clearly made a great effort to help Mrs. Dawe, a thirty-nine-year-old widow, as sufficient money had been subscribed to keep her three children for four months and 'it was decided that if she was doing well in her training, steps would be taken for the other five months.' However, the matron at the training home 'did not give a good account of her capabilities ... [and] came to the conclusion she would have much to learn before she could pass an examination. The Committee decided not to continue Mrs. Dawes training as they did not think she had the necessary qualities to make a good Village Nurse.'
The VNMs were expected to pass the CMB examination, that is, the same midwifery qualification as QNs, who were already trained nurses. As we have seen, many QN candidates lacked the level of literacy this required, and the working-class VNM trainees encountered the same difficulties. This clearly caused a national problem, as in 1909, at a meeting of CNA representatives at QVJI's London offices, one of the subjects discussed was the need to simplify 'the technical terms employed in the CMB examination.'68 In 1906, Margaret Loane, a distinguished QN, wrote a textbook, Simple Introductory Lessons in Midwifery, explaining medical terms. In the same year, the Gloucestershire CNA Committee agreed that Mrs. Shaw, in training at Plaistow, would have '6d per week sent to her for books, etc.,' and in 1907, the county superintendent was audiorized 'to spend a sum of between 20/- and 30/- on books to be lent to pupils in training.'69
Despite such help, candidates continued to struggle, and there are frequent references in the Gloucestershire CNA Minutes to nurses having to repeat the CMB examination. Nurse Conry managed to pass the written paper in June 1910, but failed the oral examination, which she passed at her second attempt a month later. Nurse Higgs and Nurse Harris both failed the CMB examination in August 1910 but passed in October. Nurse Aston passed at her second attempt in January 1913, while Nurse Sims only passed at her third attempt in February 1913. In 1912, 'Nurse Burchill training at Plaistow was reported by the Superintendent to read and write so badly that it was feared she would not be able to pass the CMB examination. It was decided she should attend a night school while at Plaistow.'
Other candidates failed to complete their training. Halfway through her course in 1910, Nurse Powis decided that 'owing to family matters [she] did not wish to complete her training and re-paid the fees.' In the same year, Nurse Corkhill left Tipton after just one day 'owing to her husband's illness. As she had stated that she was a single woman the Committee decided not to allow her to return.' In 1911, Pearl Loveridge 'returned home from Plaistow in bad health after 7 months training,' while Mrs. Sinclair, having 'left Plaistow during her training without permission, was interviewed by the Committee and promised to repay the sum spent on her.'
Those who did complete their training were reported to have 'all done well,'70 and in 1910, the value of VNMs was stressed in the Queen's Nurses Magazine. 'What they know, they know well - they are of the country, understand the people, and are happy amongst them.... Queen's Nurses are needed in increasing numbers, ... but under the pressure of the Midwives Act, ... the village nurses are also needed for the posts they alone can fill.'71
The necessity of balancing the technical content of the training with the caliber of candidates remained a problem, particularly as the scope of their duties increased with the expansion of public health work after 1908. This involved health visiting, maternity and infant-welfare clinics, inspection of schoolchildren, and tuberculosis care. The nurses were expected to fulfill these duties in addition to their routine nursing and midwifery cases, and the VNMs were expected to carry the same weight of responsibility as QNs, despite their shorter training and lower wages.
The outbreak of World War I in 1914 also affected the recruitment of trainees, as many potential candidates took up war work in various capacities. In 1916, the Gloucestershire CNA noted that it was 'very difficult to obtain candidates for training,' and in 1917 a letter by the Duchess of Beaufort 'calling attention to the need for women to train as District Nurses' was sent 'to all the newspapers in the County.'72 By endorsing a similar national appeal by the president of the Hampshire CNA, the duchess acknowledged the 'splendid desire ... [of] women to serve the country by war work,' but she strongly recommended that, instead of 'eagerly undertaking temporary employment where litde training is necessary,' women should consider training as VNMs and thus 'fitting themselves to do permanent service for their country... [as] an integral part of our health organisation.'73 The response to the original national appeal is not known, but in Gloucestershire twelve applications were received, although 'some of these would not accept the conditions of training and some were not suitable but it is hoped 2 at least will be trained.' Later that same year, 'a letter was sent by the secretary to all local associations asking if they could recommend candidates for training,' but only two women applied.74
At that time, Gloucestershire VNMs were given 'careful instruction' in health work by the county superintendent as part of her supervisory duties, but at a Conference of Superintendents in London in 1919, it was considered desirable that such instruction should become an integral part of their training.75 At the Conference of Superintendents in 1922, a resolution was passed 'to the effect that the period of training for Village Nurses should be extended to one and a half years, and that three months ofthat time should, if possible, be devoted to school work and health visiting.'76 In Gloucestershire, an extra three months instruction in health work was added to the one year's training in 1922/3, and in 1925/6, it was reported that the county's VNMs 'will now receive eighteen months training, one year in Midwifery and six months in general and Health work' and 'to bind for a period of two years instead of three.'77
In 1924-5, the Gloucestershire CNA reported that, although the number of applicants had increased, 'very few of these are suitable for the work.'78 A breakdown in health was still the most frequently cited reason for candidates failing to complete their training: Nurse Prince at Kingswood in 1920; Nurse Markham after only a fortnight's training in 1921; Nurse Wilkins, who had been at Kingswood for three months in 1923; Nurse Hepburn, who spent sixteen weeks in training at the Victoria Home, Cheltenham, also in 1923; and Nurse Smallbones, who broke her contract at the end of three months training in 1924, 'being too nervous for the work.'79 In 1925, it was recorded that 'it has not been possible to keep the vacancies at Kingswood filled during the whole year,' and the CNA expressed 'regret and surprise that many more women do not feel a vocation to a life so full of human interest and personal devotion.'80 However, in a paper delivered at the Conference of Superintendents in 1922, Miss Johnson, the county superintendent for the Isle of Wight, pointed out that with the implementation of the Registration Act, 'the most eminendy suitable women would consider the county training not worth while' because, on the completion of her training, each candidate 'will not be a fully qualified nurse... [and] she will be unable to come into any scheme for the benefit of fully trained nurses.'81 In Gloucestershire, attempts were made to recognize the quality and professionalism of the VNMs by the introduction, in 1919, of a certificate 'for nurses leaving the County after fulfilling their contract and having worked satisfactorily,' and in 1920, by the wearing of a county badge: a white enameled badge during a nurse's first two years of service, then 'if satisfactory,' a red badge.82
Despite such ongoing problems and concerns, VNMs remained invaluable. In England and Wales as a whole, they represented 25.44 percent of QVJI nurses in 1905; by 1925, this figure had risen to 62.38 percent, a percentage increase of 36.94. In Gloucestershire, a predominantly rural county, VNMs as a percentage of QVJI nurses rose from 57.14 in 1907 to 82.44 in 1925. In a report dated 1926, the county medical officer of health described how 'much useful work has been done by the Distria Nurses in the County and the value of their services as health agencies in the homes becomes more obvious as time goes on. It is scarcely stating too much to say that there is no other service which has such full opportunity for promoting the general health of the country, for the home is the unit of health work, and the District Nurse enters it more intimately than can any other health official.'83
Although professional resentment persisted nationally, in Gloucestershire the dual system of QNs and VNMs, both combining district nursing with health work, was clearly a success, and in its report of 1925/6, the Gloucestershire CNA recorded with pride that 'the combination of State and Voluntary Work as carried out in this County is held up as a model all over the Country.'84
Conclusion
The work of rural district nurses demanded skill, tact, and stamina, if they were to achieve their dual aims of improving the lives of their working-class patients and caring for them. Although the QNs were expected to be 'ladies,' the Queen's Roll suggests diat, initially, district work appealed more to young women from a middle-class background and by the interwar period was attracting candidates from the upper working classes. Although, as a consequence, educational difficulties were frequently cited as a cause for concern, QVJI's demanding training, unique system of inspections, and centrally held records provided the means to carefully monitor each nurse from her initial training to each post she subsequendy held. Hence, any problems were identified, recorded, and dealt with to ensure standards were maintained.
Poor literary skills were also a major problem in the recruitment and training of VNMs, with many candidates having to repeat the CMB examination before they passed at the second or even third attempt. Poor health prevented some candidates from even completing their training and those who did qualify found themselves excluded by the Registration Act of 1919. However, the VNMs represented an integral and invaluable part of the national rural district nursing scheme, and the organizational structure of QVJI remained unchanged until it was absorbed into the NHS in 1948.
Those nurses, both QNs and VNMs, who did prove suitable for rural district work derived a great sense of satisfaction and social status from their combined duties of nursing, midwifery, and public health work. In late nineteenth- and early-twentieth-century hospitals, all patients were referred to by their bed number, and nurses were frequently changed from side to side in a ward to prevent them from getting to know any patient too well. It was also traditional to call senior nurses by the names of their wards (e.g., Sister Clinical) instead of by their own surnames.85 In contrast to such an impersonal atmosphere, rural district nursing offered the opportunity to befriend entire families and to occupy a position of trust and respect within the community.
Among the QNs who served in Gloucestershire, where the rural movement began, Alpha Fenton worked at Charlton Kings for seventeen years and her successor, Ann Newdick, for twenty-four years; Rose Paling worked at Lydney for sixteen years, Beatrice Price at Stone for eighteen years, and Lucy Avery at Nailswordi for twenty-four years. Among the longest-serving VNMs in the county, Nurses Shaw, Kite, Self, and Fitzgerald were already either married or widowed when they began their training, while two of the longest-serving QNs remained in their posts after marriage, Nurse Price becoming Mrs. Pullir in 1927 and Nurse Avery becoming Mrs. Abbotts in 1936. VNM Nurse Bridges, who worked for the Coin St. Aldwyn DNA from 1917 to 1927, was allowed to continue in her post when she became Mrs. Day in 1922, when she informed the committee that 'she would like to settle down' in the area.86 Similarly, VNMs Nurse Hill, appointed to Kings Stanley in 1919, and Nurse Cooper, appointed to Wotton-under-Edge in the same year, both remained in the same posts when diey married in 1925, becoming Mrs. Miles and Mrs. Witchell, respectively. This, of course, was in marked contrast to hospital nurses, who were expected to resign on marriage, and it must have been an inducement to those who wanted to combine a family life with paid service to the community of which they had become an integral part.
In evaluating the success of the district nurses, it must be remembered that QVJI was a charity and the poor were not obliged to use its services. The Midwives Act of 1902 forbade the practice of midwifery other than by trained and registered women, but no such act was passed to prevent unqualified attendance to the sick and dying. The fact that the rural district nurses overcame deeply entrenched local customs and prejudices and established themselves as part of village life is a testament to the self-effacing and hardworking majority and, clearly, the nursing, midwifery, and health care they provided was welcome. However, the success of the educational aspects of QVJI's aims is more difficult to quantify or qualify. During the late nineteendi and early twentieth centuries, policy makers, social investigators, and philandiropists paid increasing attention to the problems of poor families and subjected them to increasingly close supervision. Concern over the poor physical condition of army recruits during the Boer War between Britain and the Dutch colonists in South Africa (1899-1902) had generated a national campaign to improve the health and welfare of the young, but government intervention was limited by the ccepted belief that family responsibilities provided the best and greatest incentives for men to work. Even after the Insurance Act of 1911 and the provision of the first sickness and maternity benefits, successive governments resisted calls for further direct economic assistance, such as family allowances. As one of the main agencies of care and health education, the scope of QVJI's services was, therefore, confined within government policies that were designed to inculcate a sense of moral responsibility without increasing the financial burden of the country's economy by directly relieving the problems of poverty and poor living conditions.
Nevertheless, the poor recognized and appreciated the advantages of the professional care that QVJI's nurses could offer. At Upton St. Leonards in Gloucestershire in 1908, the county superintendent reported that Nurse Goddard 'is loved by her patients ... [and] it was a pleasure to go round the district with her,'87 while at Gotherington in 1911, Elizabeth Malleson noted that 'Nurse Griffiths has already won her place amongst us by her habitual manner of regarding patients not only as 'cases' in nursing parlance, but as neighbours and friends requiring her skilled help.'88 Mary Paget, who was delivered by Nurse Ann Newdick at Charlton Kings on a Sunday morning in 1912, recalls, 'She was absolutely wonderful and much respected in the village.'89 Alexina Cowee was 'a kind, unselfish and attentive nurse. Much liked.'90 Lily Tatton was 'conscientious and hard-working, kind and with a gentle manner,'91 and Lucy Avery was 'a keen and energetic nurse, much appreciated by doctors and patients.'92 At Nailsworth in 1920, it was recorded that 'the Nurse is welcomed everywhere.'93 By 1924, the Gloucestershire CNA was 'particularly glad to be able to report that... the desire to have a Nurse in practically every parish comes from the people themselves, and is a gratifying proof that the quiet devoted work of the Nurses in the homes for the past twenty years and more is bearing fruit.'94
The appreciation felt by the poor was often displayed by simple but touching gestures. One of QVJI's most stringent rules was that 'the nurse shall not accept any presents from patients or their friends,'95 but at Upton St. Leonards in 1907, the DNA Committee found it necessary to modify this rule by the addition of the clause 'other than flowers or fruit.'96At Gotherington in 1913, Elizabeth Malleson recorded that 'one suffering woman on her death-bed begged that the Nurse might be asked to accept the gift of one of her possessions as a token of her care and help; such a gift was against official rules, but in my mind such a wish left no obligation but obedience to it.'97 The DNA Committee at Nailsworth was also willing to interpret the rule flexibly, as it was noted in 1925 that Nurse Avery 'frequently tells the Committee members that on her return home from work she finds on her doorstep gifts of a few plants, flowers, a few eggs, a pot of jam, and similar marks of gratitude from an appreciative public.'98
Overall, QVJI failed to attract the class of recruits that its founders and leaders originally envisaged, particularly in rural areas, where it proved necessary to introduce a second grade of nurse. The district nurses did take a greater level and scope of care into the homes of the rural poor than had ever been available to them before, but although the services they offered did much to relieve the effects of poverty, social policies failed to solve the underlying causes. Nevertheless, with its combination of home nursing, midwifery, and public health work, and its national system of inspections and centrally held ongoing records, rural district nursing, more than any other branch of the profession, came closest to fulfilling Florence Nightingale's vision of the future of nursing, while the nurses themselves, both QNs and VNMs, whether single, married, or widowed, could live as part of a community in which their work was rewarded with the hard-won respect, affection, and gratitude of their poor patients.
Notes
1. For example, see the two classic texts on nursing in England, Brian Abel-Smith, A History of the Nursing Profession (London: Heinemann, 1960) and Christopher Maggs, The Origins of General Nursing (Beckenham, Kent: Groom Helm, 1983).
2. Mary Stocks, A Hundred Years of District Nursing (London: Alien & Unwin, 1960); Monica BaIy, A History of the Queen's Nursing Institute (Beckenham, Kent: Groom Helm, 1987). The title QVJI was changed in 1928 to the Queens Institute of District Nursing and later still to the Queen's Nursing Institute. Throughout this article, which covers the years 1880 to 1925, the original title is used.
3. Baly, History of the Queen's Nursing Institute, flyleaf.
4. Cecil Woodham-Smith, Florence Nightingale (1950; reprint London: Book Club Associates, 1972), 539.
5. Stocks, District Nursing, 43.
6. Florence Nightingale, Letter, The Times, April 14, 1876, page 6.
7. The Lancet, April 22, 1876, pp. 610-11.
8. Nightingale, Letter, April 14, 1876.
9. The Lancet, April 22, 1876, pp. 610-11.
10. Nightingale, Letter, April 14, 1876.
11. The Lancet, April 22, 1876, pp. 610-11.
12. EK. Prochaska, Women and Philanthropy in Nineteenth Century England (Oxford: Oxford University Press, 1980), 98.
13. Rosalind Nash, ed., Florence Nightingale to Her Nurses: A Selection from Miss Nightingale's Addresses to Probationers and Nurses of the Nightingale School at St. Thomas' Hospital, 1872-1888 (London: Macmillan, 1914), 45-7.
14. Baly, Queen s Nursing Institute, 31-2.
15. Gwen Hardy, William Rathbone and the Early History of District Nursing (Ormskirk, Lanes: Hesketh, 1981), 49.
16. See Carrie Howse, 'The Development of Rural District Nursing in Gloucestershire, 1880-1925,' PhD thesis, University of Gloucestershire, 2004.
17. Committee of QVJI, Letter, The Times, January 7, 1888, page 8.
18. Editorial, The Times, January 7, 1888, page 9.
19. F.R.C.S., Letter, The Times, January 18, 1888, page 9; Isaac Butler, Letter, The Times, January 21, 1888, page 4.
20. Florence Nightingale, 'Sick-Nursing and Health-Nursing,' in Baroness Angela Burdett-Coutts, ed., Woman's Mission: A Series of Congress Papers on the Philanthropic Work of Women by Eminent Writers (London: Sampson Low, Marston, 1893), p. 186.
21. Nightingale, 'Sick Nursing,' p. 192-4.
22. Nightingale, 'Sick Nursing,' p. 195.
23. Nightingale, 'Sick Nursing,' p. 200.
24. Florence Craven, A Guide to District Nurses and Home Nursing (1889; reprint London: Macmillan, 1894), 1-6.
25. Gloucestershire Record Office, D4057/14 (hereafter GRO).
26. Jane Lewis, The Politics of Motherhood: Child and Maternal Welfare in England, 1900-1939 (London: Groom Helm, 1980), 121, 144, 142.
27. GRO D2410.
28. See Carrie Howse, 'Registration: A Minor Victory?' Nursing Times, 85, no. 49 (December 1989): 32-4.
29. Woodham-Smith, Nightingale, 571-3.
30. Contemporary Medical Archives Centre, Wellcome Institute, London, The Queens Roll, SA/QNI/J.3/2 (hereafter CMAC).
31. CMACSA/QNI/J.3/9-15.
32. Unattributed, 'The Conference of Queen's Superintendents,' Queen's Nurses' Magazine, 10, Part 2 (April 1913): 35-47 (hereafter QNM).
33. CMAC SA/QNI/J.3/17-23.
34. Unattributed, 'Report of Queens Superintendents' Annual Conference,' QNM, 19, Part 2 (1922): 25-29.
35. CMAC SA7QNI/J.3/24-31.
36. CMAC SA/QNI/J.3/23.
37. Martha Vicinus, Independent Women: Work and Community for Single Women, 1850-1920 (London: Virago, 1985), 109-16.
38. GROD27743/1.
39. GRO D2465 4/32-33.
40. CMAC SA/QNI/J.3/11.
41. QNM, 19, Pan 2 (1922): 30.
42. QNM, 19, Part 2 (1922): 28.
43. CMAC SA/QNI/J.3/2,9,10.
44. CMAC SA/QNI/J.3/13.
45. CMAC SA/QNI/J.3/24.
46. CMAC SA/QNI/J.3/30.
47. CMAC SA/QNI/J.3/13.
48. CMAC SA/QNI/J.3/10.
49. CMAC SA/QNI/J.3/15.
50. CMAC SA/QNI/J.3/17; CMAC SA/QNI/J.3/29.
51. CMAC SA/QNI/J.3/18.
52. CMAC SA/QNI/J.3/18.
53. CMAC SA/QNI/J.3/10.
54. CMAC SA/QNI/J.3/19; CMAC SA/QNI/J.3/23.
55. CMAC SA/QNI/J.3/15.
56. CMAC SA/QNI/J.3/17.
57. CMAC SA/QNI/J.3/17.
58. Lewis, Motherhood, 145.
59. GRO D4057/14.
60. Unattributed, 'County Nursing Associations and Their Work,' QTVAi 7, Part 1 (1910): 9-11.
61. CMAC SA/QNI/J.3/13.
62. QNM, 10, Pan 2 (1913): 36.
63. GRO D4057/1.
64. GRO D2410.
65. GRO D4057/1.
66. GRO D4057/1.
67. GRO D2410.
68. GRO D4057/1.
69. GRO D2410.
70. GROD4057/1.
71. QNM, 7, Pan 1 (1910): 10.
72. GROD 2410.
73. Gloucestenhin Echo, April 9, 1917.
74. GRO D2410.
75. GRO D2410.
76. QTVM, 19 Part 2 (1922): 27.
77. GRO D4057/1; GRO D2410.
78. GRO D4057/1.
79. GRO D2410.
80. GRO D4057/1.
81. QWM, 19, Pan 2 (1922): 29-30.
82. GRO D2410.
83. GRO D4057/6.
84. GRO D4057/1.
85. Vicinus, Independent Women, 107; Judith Moore, A Zeal for Responsibility: The Struggle for Professional Nursing in Victorian England, 1868-1883 (Athens: University of Georgia Press, 1988), 58.
86. Hicks-Beach private family papers, courtesy of Lord St. Aldwyn.
87. GROP347MI3/1.
88. GROD4057/15.
89. Interview, January 17, 2003.
90. CMACSA/QNI/J.3/11.
91. CMAC SA/QNI/J.3/18.
92. CMAC SA/QNI/J.3/31.
93. GRO D3548 3/1.
94. GRO D4057/1.
95. GRO D4057/3.
96. GRO P347MI3/1.
97. GRO D4057/15.
98. GRO D3548 3/1.
[Author Affiliation]
CARRIE HOWSE
University of Gloucestershire
[Author Affiliation]
CARRIE HOWSE, BED (HON), MA, PHD
External Member
University of Gloucestershire
30 Rothleigh
Up Hatherley
Cheltenham
GlosGL513PS
