Rituals & Myths in Nursing: A Social History

Work.

Preface

Most aspects of basic nursing, including the nurse’s approach to the patient are steeped in tradition and passed on from one generation of nurse to another. Too often they are routine without rhyme or reason. They are learned by imitation and taught with little if any reference to the underlying sciences.

Virginia Henderson, 1967

Introduction

Nurses are depicted as female and caricatured as angelic, sexy or fierce. From the tabloids’ ‘angels’ to the Carry On films’ formidable Hattie Jacques matron and buxom Barbara Windsor, to Nurse Ratched in One Flew Over the Cuckoo’s Nest, nurses are rarely just people doing a job. They are angels, dragons or sex objects.

This, despite Florence Nightingale leading the charge more than 100 years ago, to establish nurses as a workforce of demure, clean and educated girls, far away from the ‘Sairey Gamp’ slatternly image of Charles Dickens fame.

While Florence’s philosophy of nursing was about building a professional body of educated women with the right personal qualities, it could be argued that Ethel Gordon Fenwick (née Gordon Manson) took the profession to the next level. At the age of 24 in 1881, she became matron of St Bartholomew’s Hospital. She formalised the nurses’ training and improved their working conditions. She resigned her post in 1887 when she married Dr Bedford Fenwick but campaigned for the next thirty years to establish a nationally recognised register of nurses.

Although it seemed they wanted the same thing for nursing, Ethel and Florence were on opposite sides of the debate about the register. Florence felt it would undermine her philosophy of nursing as being about the right personal qualities and aptitudes. Ethel wanted a more formalised and universal three-year training programme, a more standardised curriculum and a final examination.

In some ways they both won. Formalised training and a nursing register were established in 1919. Mrs Gordon Fenwick was the first name on the register and is known as Nurse Number One and for Florence’s part, people still talk today about the importance of vocation in nursing.

The battle about nurse training continues, often dichotomised into education versus compassion as if the two cannot happen together. Nurses themselves are divided on whether their profession should be degree-based as it is now, or an apprenticeship as it was for the best part of 100 years. All are agreed it should be evidence based, as argued by Virginia Henderson. Nursing grew from a military model of rules to support the actions of doctors and as a result developed a rich culture of rituals and routine – from ward rounds to drug rounds, from preoperative theatre preparation to the cleaning and storing of equipment, from bedmaking to blanket baths. New rituals are developing all the time around technology, the completion of paperwork and the ticking of boxes as recording and checking takes over from doing.

The mention of rituals brings out two sharply divided nursing camps: those who think any sort of ritual implies unthinking behaviour resulting in ridiculous and, on occasion, even dangerous actions, and those who think ritual often has a role to play, offering security and comfort that can be part of the healing process.

This book uncovers both kinds, sharing nurses’ stories as they convey how they perpetuated these familiar myths and customs, exploring how they came about, and how they are steeped in the history of health, the military or religion.

I trained in a large teaching hospital in the 1980s and after a long break completed a ‘return to practice’ course and worked part time in a local district general hospital. My experience is limited to general hospital nursing and therefore so is this book, although I recognise that mental health and community nursing have their own rituals and myths ripe for the telling. I have not included stories from the two world wars mainly because these are so brilliantly covered in other books on the history of nursing, and because coping during the war years brought a whole different brand of rituals and resourcefulness.

Chapter 1

Without Rhyme or Reason

‘Wet behind the ears.’

The air was putrid with the smell of urine. It was dark. Even with the lights on it felt heavy and enclosed. At 4 o’clock every afternoon, the cry would go up: ‘I need to get home to make my husband’s tea,’ and, as one, half-a-dozen of the ladies on the elderly care ward at St Matthew’s Hospital, Hackney, would make for the door, coats and hats on, empty handbags over their arms. The permanent nursing staff, wise to this routine, would have locked the ward doors just minutes before to prevent a mass exodus of confused old ladies. We students were both bemused and saddened as the ladies clamoured for the life they once had.

Originally a workhouse built in the 1800s, St Matthew’s was converted to a hospital about 100 years later, at one time housing nearly 1,000 patients. By the time I arrived in 1981 there were about 180 beds or so, all for elderly patients with dementia – often referred to as ‘psychogeriatrics’, or psychiatry of old age.

I was a middle-class 19-year-old nursing student previously protected from the fact that people may grow old and poor and have nowhere better to end their days than a dark, smelly hospital ward cared for by strangers. At the time, their care was probably considered quite progressive, but to me it felt as if the old people were being warehoused and I wondered how they felt, how their families felt at having to leave them there and, most importantly, how I would get through the next three months.

All the patients on the ward had dementia and we students had little knowledge of how to care for anything other than their physical needs. For once, we were allowed to chat to them and listen to their stories. Nurses were usually meant to be too busy to talk, but on this kind of ward there was little else to do. At least here there never seemed to be sweeping consultant ward-rounds, or the need to polish the bedpans in the sluice.

Rosie worked on one of the men’s wards at St Matthew’s. She used to sit and listen to one chap’s war stories and when he offered her a Brazil nut from the bag on his locker, she happily took one. It was only when his daughter arrived carrying a box of Callard & Bowser Chocolate Brazil nuts that Rosie began to feel uneasy and slightly queasy. The daughter glanced at Rosie: ‘You’ve not been eating those, nurse?’ Rosie said she had. The daughter said: ‘Oh Dad, I’ve told you not to suck the chocolate off the nuts – it’s a nasty habit.’

Worse is Kayte’s account of one old lady who loved to prank the medical students. She spent hours rolling poo into Malteser size balls and putting them in a Malteser box. The nursing staff had to warn the students not to take one if she offered them.

The physical care of the ladies on my ward at St Matthew’s mostly involved encouraging them to wash and to dress in their usual clothes rather than staying in hospital-issue nighties. This was quite a battle, and once a week, they were all ‘persuaded’ to have a sit-down shower. This usually involved a lot of kicking and screaming from our charges. Once in the shower, at least three nurses were required – one to hold the shower and placate a frightened old lady, one to wash and the third to dry them and help them get dressed.

Older people often eat and drink poorly and are inactive. This can affect their digestive systems, resulting in constipation and incontinence. I don’t remember diet being considered too much – there was certainly no restriction on the intake of chocolate Brazil nuts! But there were a variety of medicines to encourage working bowels. We did not resort to the weekly ritual that Jane encountered at one hospital in which she worked in the late 1980s; Friday morning meant ‘bowel care’ and all the patients were given an enema and sat on commodes facing each other in a circle.

At St Matthew’s, once the routine of washing and dressing was complete, the ladies had nothing more to do than sit in the day room in an archetypal circle with the television occasionally on in the corner. Those likely to escape were pinned into their chairs by a tray that bolted across the front, rather like a high chair; quite rightly, these are banned today.

My friend Anne-Marie brought in a cassette radio and played a tape of 1940s songs, leading a singsong which the women thoroughly enjoyed. I wish I’d had her confidence. The permanent ward staff were thrilled – as if they had forgotten that they too could entertain their long-term charges.

It was Anne-Marie who persuaded me to take up my place at St Bartholomew’s Hospital. My heart was set on college and journalism but she persuaded me it would be three years of fun. I could also see the valuable life experience that nursing would offer to a would-be writer. That, and it would please my mother.

As the offspring of a doctor and nurse parentage (andgrand-parentage), there was little escape from the trajectory on which my brothers and I found ourselves. That we should all end up at the same hospital for the same three years, at the family alma mater, felt pre-determined. They as medical students, me as a student nurse.

Similarly, Caroline, who also comes from a comprehensively medical/nursing family, felt almost ‘compelled’ to do nursing from a very early age.

I was given a nurse’s uniform at about age three or four, and from then on it didn’t occur to me to do anything else other than nursing. In my early teens I did consider medicine briefly but rapidly realised that I didn’t have the brains or application to study that hard! I also had this romantic idea about nursing and the pretty uniforms.

Nursing, teaching and secretarial work were the employment destination for generations of women throughout the twentieth century. At one time nursing was about the only way that young women could leave home, have somewhere to live and earn an income, exchanging (often unwittingly) a suffocating home life for the excessive discipline of nurse training.

To Ruby, a 94-year-old former fever nurse, nursing represented every young girl’s dream just as it did for Caroline, a generation or so later. She had worked in a munitions factory and hated it; her father didn’t want her to go into the forces, so she was able to follow her dream of becoming a nurse. She did two years at Old Sarum Isolation Hospital before matron recommended her for SEN training which she completed at Ham Green Hospital, Bristol.

While it may be a childhood dream for some, there are also plenty who take up nursing almost by accident. For, as Dr Natalie Doyle, nurse consultant at the Royal Marsden NHS Foundation Trust, London, says, her friends were going off to university and she wondered what she would do. ‘In the end, my Mum took charge and suggested I be a nurse.’

Natalie says the practicality of nursing, and later the opportunity she had to study and so contribute to an improvement in patient care, was incredibly rewarding. There are all kinds of nurses, she says: you can be with patients on the wards or in the community; you can be academic or political, influencing policy for the better of the profession and ultimately patients.

Less interested in how I would influence nursing and more in how nursing would influence me, my mother’s unexpressed hope was that I would meet and marry the right calibre of man – a doctor obviously. After all, what had worked for her was surely right for me. I can report that despite some lame effort on the romance side, I entirely failed in this department. My brothers did much better. Both are doctors married to nurses and each has a child who is a doctor. Both my sisters-in-law are the daughters of doctors, with one, Elizabeth, the daughter of a doctor and nurse/midwife.

My father was the son of a doctor and nurse, and his sister, Molly, was also a nurse and midwife. My grandparents met on a fever ward in south London. She the redhaired petite ward sister, he the dashing young French doctor who later went on to teach and write textbooks on infectious diseases and was part of the team researching a vaccine against diphtheria. The experience of seeing young children on the infectious disease wards requiring tracheostomies and sometimes dying from diphtheria drove him on.

My grandmother, who was also a midwife, opened The Grange nursing home in Wimbledon – a maternity home for women giving birth. Pre-NHS days, couples paid a small amount each week during a woman’s pregnancy towards the cost of being delivered in the comfort and safety of the nursing home. It was here that my father and his sister were brought up, mixing with the nursing staff and the elderly patients who were also catered for on the top floor of The Grange.

My parents met at St Bartholomew’s Hospital in the 1950s; he a bright medical student who spent too much time producing the annual Hospital Revues and playing the piano in local pubs, she qualified, and nursed in New York for a year before returning to marry and bring up a family of would-be doctors and nurses. St Bartholomew’s Hospital also played cupid to my older brother, while my other brother travelled all the way to South London where he met Mary Anne, a second-year student nurse at St Thomas’s Hospital.

Part of his education as a medical student was to spend a week as a nursing auxiliary (care support worker). He presented for duty on Phipps ward at the South Western Hospital, home to mostly long-stay patients who had conditions such as polio, Guillain-Barré syndrome and motor neurone disease. Many of them were nursed in iron lungs, which are negative pressure ventilators helping people to breathe when their chest muscles no longer work.

All staff had to try out an iron lung so they could understand how they worked and what patients experienced, so later that day brother Stephen found himself in an iron lung. A typical test is to get the patient to count from one and as the machine forces them to take a breath so they are unable to make any sound although you can see them mouth the numbers, then as the machine relaxes so they can make a sound again. Mary Anne jokes: ‘You could say I took his breath away on the first day we met!’

For them the rest is history. Romances that blossom within hospital often work because each understands that world, the extreme highs and lows and the overwhelming hours and demand.

For Caroline, who trained as a nurse and married a GP, this was certainly the case. Her brother and sister are both doctors, one married to a nurse, one to a doctor, while their parents met at medical school. It is who you meet, she says, as well as the common understanding of what the job involves. ‘The horrors that we saw day to day at work creates a certain bond and puts you in a sort of club I think where you have a lot in common.’

For a long time, marriage was a bar to nursing. If you married you had to leave the job. There are many stories of (female) nurses who kept their marriage secret from their employer. It’s not clear if this stemmed from society’s belief that married women of a certain status shouldn’t work, because nurses were expected to ‘live-in’ at the hospital and men were not allowed in the nurses’ home, or whether it was a leftover from religious orders when nuns were married to God. Were nurses married to their patients? For many years, it appeared so, as so much was demanded of them and they had very little time off.

For a long time, especially post First World War, ward sisters were single women who stayed in the job for a lifetime, living in rooms just off the ward. In part this reflects an era when a generation of young men had been decimated by the war and by the 1918 ’flu epidemic. There were many single women needing a home and to earn a living. The Second World War increased the opportunities for work, although often nurses had little choice whether they would be deployed on the home front, which was in need of nurses and midwives in particular, or abroad as many wanted.

Changes in the demography of nurses came slowly after the Second World War, with unmarried, young, white females still predominating. Male nurses held sway in mental health nursing but there were few in general nursing, many of whom were thought to be gay for no other reason