They will be paid £10 during the year of Probation. This will be in addition to the uniform.
At the close of the year their training will usually be considered complete, and during the two years next succeeding the completion of their training they will be required to enter into service as Hospital, District or Private Nurses, in such situations as may from time to time be offered to them by the Lady Superintendent, and will receive £20 the first, and £21 the second year, with indoor uniform.
The names of the Probationers will be entered into a Register, in which a record will be kept of their conduct and qualifications. At the end of a year those who passed satisfactorily through the course of instruction and training will be entered in the Register as Nurses, and will be recommended for employment accordingly. After the three years’ term is completed, engagements may be terminated by a month’s notice on either side.’
The Regulations also included the required text of a letter, to be sent by each Probationer to the Chairman of the House Committee of the Edinburgh Royal Infirmary, one month from the date of entry, confirming her commitment to the three year term:
‘SIR, – Having now become practically acquainted with the duties required of an Hospital Nurse, I am satisfied that I shall be able and willing, on the completion of my year’s training, to enter into service in a Public Hospital or Infirmary, or as a District or Private Nurse, and I engage, in accordance with the Regulations of the House Committee, and in return for the advantages bestowed upon me, to continue in such service for the space of at least two years, in whatever situations may be thought suitable to my abilities. I am, SIR, etc., etc.’
Such a controlled environment was entirely the norm in the new world of more professional and respectable nursing. And the Edinburgh school came highly recommended. Florence Nightingale wrote a note to her god-daughter at the beginning of her training, in a letter dated January 3rd 1893, expressing approval at her choice of institution:
‘Dear Florence Shore – In answer to yours that you are now at Edinburgh, accepted by Miss Spencer as a Probationer, and a better Hospital, and a better Nurse Training School you could not be in, let me wish you a good New Year, and give you joy that you are accepted at the Royal Infirmary School as Probationer. Many good New Years. Yours sincerely, Florence Nightingale.’
So Florence’s nurse training began at a chilly Scottish New Year, on a salary of £10 per year with uniform, food and accommodation. Her training record shows that, during her probationer year, ‘she was almost twenty-six weeks in Medical Wards, nearly twenty six in Surgical, and on leave for three days.’ At the end of this exhausting and demanding year, Florence’s supervisor reported on her impressions of the new Nurse Shore. They must have come as a harsh blow to Florence, carrying the weight of her godmother’s name and her father’s history at the same institution, and after a year of such hard work.
‘She proved kindly, fairly capable’, the note on her training record begins, optimistically, before following up with ‘not very bright or thoughtful, nor possessed of tact. She did not carry out the promise of the first few months.’
Yet Florence must have impressed some of her tutors: she was awarded second prize in anatomy and physiology, and presented with two books, ‘Shakspere’s Works’ and Norris’ Notes, by Charles W. Cathcart MB, FRCS, Lecturer.
In spite of any misgivings about Nurse Shore’s performance, the Infirmary did not – as it could have – decide to extend her training by the extra three months. Instead, Florence was taken onto the staff on 1st January 1894 as an ‘Extra Night Nurse’. Her routine in this post is set out in instructions to the night staff:
‘Early tea, to be put round at 5.30am, and bed-making and washing may be commenced immediately afterwards. The nurse must not disturb any patient who is asleep until after 6am. (Helpless patients who are awake may be washed between 5 and 5.30, but the other patients are not to be disturbed.) The sideward beds are not to be made until after 7.15am.
The temperatures, pulses and respirations to be taken by the day nurses, excepting in the case of patients on four-hourly charts. The night nurse must pay constant attention to the freshness and ventilation of the ward…
The night nurses will set up patient’s breakfast trays, and clean one turret. Centre lights must not be put up until 6am, and if side lights are required they must be shaded. Blinds not to be pulled up till after 6am. Sideward patients to be visited at regular intervals. Sideward doors to be left open from 10.30pm onwards.
Night Nurses must not visit other wards, or go into the grounds or across the balcony during the night, and they are requested to be quiet in the corridors when going to and from the dining room for meals.’
Later, Florence returned to day duty, and she was sent to a variety of different wards as she worked out her two years’ contracted service at the hospital. By this time, she was earning £21 a year – equivalent to around £5,000 today.
It was during Florence’s second year at the Royal Infirmary, in April 1894, that Mabel Rogers came to Edinburgh for her nurse training, and the two women met for the first time. Mabel was almost exactly the same age as Florence. Her father was a solicitor; she came from a family of four girls in Reading and went to school in Oxfordshire. It was reported that Florence and Mabel ‘became great friends at once.’ It was a friendship that would last for the rest of Florence’s life, and see their two careers run inseparably throughout that time. When Florence finished her required two years’ service at the hospital (plus an additional nine months) and left for a brief holiday, in September 1896, Mabel still had a year’s service to work. During this time Florence went to the Rotunda Hospital in Dublin to learn midwifery. She would complete the course in May 1897, at the age of 32, at the same time as Mabel finished her two years’ service in Edinburgh. Florence’s stay in Dublin would be almost the last time they were separated for 17 years.
Chapter 11
The man midwife of Dublin
By the time Florence started her training, men had effectively muscled in on the business of attendance at childbirth.
They had been interested in it for centuries: Leonardo da Vinci was drawing babies in the womb, based on knowledge gained through dissection, as early as 1500. The first printed book on midwifery (by a man) was published in 1513 and other major works appeared in the 17th and 18th centuries. It was during these centuries that the ‘man midwife’ became commonplace. Man-midwifery dissected, published in 1793, actually argued against the trend. It depicted men midwives surrounded by instruments and medicines, while the woman midwife was shown in a domestic context, implying a more natural and gentle approach. Apart from different approaches to the birth itself, there were also strong factions which regarded a man’s involvement at the birth as simply indecent. Morals and methods aside, though, there is no doubt that the men midwives contributed a great deal to the knowledge about childbirth and the procedures surrounding it. They were responsible for the invention and refinement of many familiar elements of modern childbirth: anaesthesia, forceps for difficult deliveries, and obstetric surgical procedures. And in Dublin, the hospital itself owed its existence to the passion and persistence of a man midwife.
The Rotunda Hospital (Ospideal an Rotunda), which Florence chose for her training, was another famous and venerable institution. It had been founded in 1745 by Bartholomew Mosse, a surgeon and man-midwife, as the ‘Dublin Lying-In Hospital’. Mosse was born in 1712, and served an apprenticeship to a Barber Surgeon in Dublin. From 1733 he practised as a surgeon and man-midwife. Midwives at this time had no special training, but could be licensed by Royal College of Surgeons in Dublin; following trips to Europe to develop his midwifery knowledge, Mosse obtained his licence from the College in 1740. The winter of 1739 to 1740 had seen a dreadful potato famine in Ireland, and the appalling conditions in which destitute mothers gave birth were the spur for Mosse to found a hospital to provide for these mothers in Dublin. He also wanted to train midwives and surgeons to care for m
others in the other counties of Ireland.
The first premises of the Dublin Lying-In Hospital were a former theatre, which opened as the hospital in 1745. As the number of women needing its services rapidly outstripped the facilities, Mosse raised funds for a new, purpose-built hospital through a combination of fundraising events – plays and performances of Handel Oratorios – and lotteries which he ran himself. For one of these he was charged with fraud and arrested in Anglesey. He escaped to mainland Wales and eventually back to Dublin, where he managed to explain away the misunderstanding over his handling of the lottery money. Mosse worked with the architect Richard Cassells on the design for the new hospital, insisting on small wards – which later helped to limit the spread of the often-fatal puerperal (childbirth) fever – as well as a tower on top of the building which, while having no practical purpose, became a famous symbol of the hospital. The Rotunda name came from one of amphitheatres included on the site as venues for fundraising activities.
The hospital was awarded a Royal Charter in 1756, which set up a system of Masters for the institution, each to serve a single seven year term, which has continued ever since. The new hospital opened the following year, making the building already 120 years old when Florence arrived, while the institution itself had more than 150 years of history. Mosse did not live to see his new hospital in action for long. He died in 1759 at the age of forty seven, in poverty, and was buried in an unmarked grave in Donnybrook Cemetery.
Florence’s midwifery training followed a long period of development and some bold new experiments in the care of women giving birth. Chloroform had been used in the Rotunda for forceps deliveries from the mid-1800s. A home birth service had been established twenty years before Florence’s arrival, incubators were being used for premature babies, and the first Caesarean section at the Rotunda was performed just 10 years earlier. More than one hundred sections were carried out during the Mastership that ran from 1889 to 1896. By 1896, the Master (the wonderfully-named Dancer Purefoy) was reporting the extensive use of gynaecological surgery, and the opening of the first Pathological Laboratory at the Rotunda.
But it was not all progress and success at the hospital. Puerperal fever came in epidemic waves, as it did at all maternity institutions, killing many of the mothers. And the doctors struggled to find ways to reduce the rate of infant mortality, which at times was as high as one baby in six, without a full understanding of infection control, and without antibiotics. All they could think of was increasing the ventilation of the wards. Florence must have seen many tragic losses and much grief during her midwifery training: experience that would stand her in good stead for future work in two war zones.
As soon as she was back from Dublin, Florence and Mabel enrolled at the Queen Victoria Jubilee Institute for Nurses in London, and started their district nurse training there in June 1897. They were about to become ‘Queen’s Nurses’.
Chapter 12
‘The story of a successful experiment.’
‘Hospitals,’ Florence Nightingale wrote in 1876, ‘are but an intermediate stage of civilisation. At present hospitals are the only place where the sick poor can be nursed, or, indeed, often the sick rich. But the ultimate object is to nurse all sick at home.’
Florence Shore’s godmother is chiefly remembered for her influence on the nursing of wounded soldiers, and the organisation of hospital nursing. But she was also a prime mover in the founding of district nursing, and took a close interest in the development of nursing in the home throughout her life.
The idea of an organised system of nurses specially trained to care for people in their own homes originated with William Rathbone (the sixth of the name), a Liverpool merchant and philanthropist. When his wife was gravely ill following the birth of their fifth child in 1859, Rathbone engaged a nurse, Mrs Robinson, to care for her. Mrs Robinson was to have an enormous influence on her employer. She demonstrated ‘the great comfort and advantage derived from trained nursing, even in a home where everything which unskilled affection could suggest was provided,’ as Rathbone later wrote in his own history of district nursing. After his wife died, Rathbone engaged Mrs Robinson for a further three months, to take her nursing skills into the homes of the ‘sick poor’ in Liverpool.
After only a few weeks, however, she baulked at the task. Rathbone records:
‘She returned to her employer and entreated to be released from the engagement. Accustomed though she was to many forms of sickness and death, she was not able to endure the sight of the misery which she had encountered among the poor.’
This is hardly surprising. Liverpool was in the throes of a population explosion: from a population of 75,000 in 1800, the combination of famine in Ireland and the growing trade with America through Liverpool’s port had brought thousands more people flocking to the city. By 1871, the city had more than 490,000 inhabitants, thousands of whom lived in windowless cellars, in spite of efforts to clear them after the Liverpool Sanitary Act. Thousands more lived in court houses: tall, narrow buildings with one room on each floor, built around a courtyard and back-to-back with other courts, restricting the flow of fresh air. Whole families shared single rooms in these houses, and sanitation was primitive, with only one or two toilets for the whole court. The one tap in the courtyard, serving everyone in the court house, was often only operational for part of each day. Infectious diseases such as typhus and cholera were commonplace, poverty led to all the ills of malnutrition, and there was virtually no organised health care available to people who could not pay for it, other than the workhouse hospitals.
Of these, Rathbone had considerable knowledge. He had already been involved in trying to improve standards at the Brownlow Hill workhouse infirmary: an institution of 1200 beds, overseen by two female officers, who, though not nurses themselves, supervised the nursing. They were assisted by pauper women ‘who’, Rathbone observed, ‘were as untrustworthy as they were unskilful’.
In spite of the huge number of beds, the hospital was over-subscribed, with three or four patients to a bed – not all of whom, in Rathbone’s view, needed to be there:
‘Many of the male patients with sore arms and legs were mere malingerers, who thought it more agreeable to hang round the fire and be pampered with hospital diet than to earn their own livelihood by working outside’.
After consultation with Florence Nightingale – with whom Rathbone collaborated and corresponded throughout his life – Miss Agnes Jones was brought in, with nurses from St Thomas’s Hospital in London, to tackle the hospital’s problems. She immediately began to reduce the numbers of patients, and attempted to introduce training for the pauper women. Both Rathbone and Florence Nightingale were devastated when Miss Jones died after just two years in post.
‘Exhausted by her unremitting labours’, Rathbone wrote, ‘Miss Agnes Jones sank under a severe attack of typhus fever. In the church of the workhouse the beautiful ‘Angel of the Resurrection’ by Tenerari, with inscriptions by Miss Nightingale and the Bishop of Derry, preserves the memory of her life and death.’
Mrs Robinson, meanwhile, was persuaded to stay on in spite of her misgivings, and continue her work with the sick poor in their own homes. She found, Rathbone reported with satisfaction,
‘ … that she was able to do great and certain good… patients who had been given up as hopeless by the doctors; patients who, without the assistance of skilled nursing, would have been hopeless even in well-provided homes, were restored to health by the aid thus afforded.’
So the model worked, and Rathbone wanted to extend the benefits of home nursing to more of the sick and needy in Liverpool. He was ahead of his time in his conviction that people were better cared for in their own homes. In his book, he sets out four good reasons for home rather than hospital care that perfectly match the arguments put forward for ‘care closer to home’ today. His arguments started with the observation that many people had chronic conditions that could not be cured, so had to be dealt with at home. In addition, people
preferred to be at home with their families; and hospitals lacked the capacity to cope with the level of demand, if everyone with any ailment needed to be taken in to hospital. Finally, he pointed out, hospital care was expensive, so it was more efficient to care for people at home.
But he ran into a problem in setting up a home nursing service. There were not enough properly trained nurses – such as those trained by the Florence Nightingale method at St Thomas’s in London – to recruit into the service. Rathbone, after his experiences with trying to improve hospital care, was absolutely convinced that a dedicated training school for nurses was the key to good care.
‘It was not quite a new idea,’ he wrote, ‘For the authorities of the Royal Infirmary in Liverpool had already realised the want of such a school. As a step towards the improvement of the nursing standard, the matron of that institution had been empowered to pay a salary of £16 to any nurse who deserved it. This salary was certainly not an exorbitant one, and yet no more than four nurses could be found worthy to receive it. Any ordinary nurse of that time, if paid more than the usual salary of £10, would most probably have incurred dismissal for drunkenness after the first quarter-day.’
Rathbone approached Florence Nightingale, who had supplied Agnes Jones and nurses for the Brownlow Hill infirmary, to see if she could spare more nurses for his district work. But all the Nightingale nurses were needed for hospital work, so Miss Nightingale suggested that he start his own training school. The Liverpool Training School and Home for Nurses was built in the grounds of the Infirmary, and paid for by William Rathbone. It was closely linked with the Infirmary, and aimed to provide ‘thoroughly educated professional nurses for the Infirmary; district nurses for the poor; sick nurses for private families’. The curriculum for district nurse training included technical class instruction in hygiene (ventilation and sanitation – students had to be able to draw a diagram of the sanitary and plumbing system of a house); nutrition and diets; fevers (diagnosis and disinfection); diseases of women; monthly nursing including the care of newborn infants; practical sick cookery; bandaging; and the use of medical and surgical appliances.
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