Nursing and Its Role in the 19th Century Medical Hierarchy – Sample

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Nurses in the 21st century may make a lot of independent decisions and have to study hard to obtain qualifications at degree level and beyond, as well as work their way upwards through various levels within their chosen profession. However, generally speaking, they still work under doctor’s orders and have a very secondary role in the medical hierarchy, a position that historically they have always held. Up until 1948, nursing was not considered an activity to require neither special professional skills nor commanded respect. Despite all the changes that the 20th century brought to the nursing profession, such as proper training for midwives and the introduction of the National Health Service in the UK (1948), it was in the mid-nineteenth century that nursing underwent its biggest change so far. Partly, it was a result of advances such as safer operations that meant more patients were going into hospitals and needing full-time care. Florence Nightingale, a woman to be considered as a founder of modern nursing profession, declared that nursing was left for those “who were too old, too weak, too drunken, too dirty, too stupid or too bad to do anything else” (as cited in Gaffney, 1982, p.139), because in the 19th century the intimate body services that were a necessary part of nursing were thought to be unfit for young unmarried and well-bred women, especially if not for a member of their immediate family. Thus, the current paper aims to discuss the impact 19th century had on a modern nursing profession.

Before the 1880’s, even in large cities, there were few hospitals, and, consequently, the hospital treatment of the sick was a rare event, though some poor houses had wards for the infirm. The only real hospital type care was in the hands of religious groups such as the Deaconesses in Dusseldorf to whom Florence Nightingale went for training (2 weeks in the first instance). In middle-class homes, a sick person was attended by the family doctor and nursed either by his immediate female family members or by the servants. From the middle of the19th century, though, with the discovery and use of both anesthetics and antiseptic surgery, there had been a huge medical development splash. The increasing women’s movement which sought both equal rights for women and their proper education made many young women from all walks of life realize that they could have a useful and successful career. The Crimean War in the 1850’s was, of course, another factor that pointed to the need for properly trained nurses – especially when Florence Nightingale was such an exponent of that need. “Miss Nightingale did inspire awe, not because one felt afraid of her per se, but because the very essence of Truth seemed to emanate from her, and because of her perfect fearlessness in telling it” (Richmond, 1978). But Florence Nightingale was about more than stirring up government action, avoiding waste and promoting hygiene. Her biographer, Cecil Woodham-Smith, in his biography ‘Florence Nightingale’ quotes one of her patients in the Crimea:

“What a comfort to see her pass. She would speak to one, and nod and smile to many; but she could not do it to all you know. We lay there by the hundreds, but we could kiss her shadow as it fell” (Woodham-Smith, 1978)

From the 1860s onwards, a series of nurses’ training schools all over the kingdom began to produce quite large numbers of educated women who were eagerly accepted by hospital authorities as both doctors and patients began to demand and expect higher levels of nursing skill in the wards than was available up until that point. Training, however, consisted only of reading and some practical instruction. Nurses might be given a copy of Florence Nightingale’s innovative book ‘Notes on Nursing’ which had been published in 1859, a work which laid down sound principles, even at the apparent expense of scientific fervor (The Natural Health Perspective, 2009). The latter roughly points to the main distinction between doctors and nurses at that time – doctors were the men of science. Their role was to diagnose and to prescribe, whereas the nurse’s role was, at a top, the make the patient as comfortable as possible, giving prescribed treatments, but not necessarily understanding the disease process to any great extent.

This ‘making comfortable’ was not just to do with the patient’s immediate personal needs, but nurses were also required to fetch coal, clean and tend oil lamps, sweep, mop, dust, and all the rest – usually work of a housemaid, and all for very little pay and hardly any time off, working 7 am to 8 pm 7 days a week with only 2 hours off on a Sunday was normal while in training. A job description of 1887 lists all these tasks as one nurse’s role, in addition to caring for your 50 patients (“Nurse’s Duties in 1887”, n.d.).

For all nurses, trainee or trained, over all, there was the matron of course, in some ways acting like the mother superior of a convent with subordinates at various levels down to the humble probationer, who could be likened to a postulant nun. Only after she had passed her initial training could she be considered to be a nurse. The nurse almost invariably lived in a nurse’s home where their comings and goings during free time (of which there was very little) were controlled with matron acting as a sort of loco parentis, even for quite mature and senior women. Nurses were needed, they were intelligent and capable women, yet often their conditioned were no better than that of a ‘tweenie’ the maid of all work in some large household. They could be in charge of a ward of 50 very ill patients, yet could be treated as if they were incapable of making the simplest decision about their own lives. There were three types of hospitals at the time:

  • Voluntary Hospitals, managed by independent boards of directors and which obtained funding from public donations
  • Poor Law Hospitals, managed and funded by the local parish under the Poor Law
  • Municipal Hospitals, which were provided by the local authority, and often used entirely for the treatment of infectious disease such as smallpox and tuberculosis (“A History of Nursing”, n.d.).

In her doctoral project, Ulrike Haider, was writing about nursing in the early 20th century, but her remarks could have applied anywhere from about 1860 onwards: “The attempts to improve basic and supplementary training met with strong resistance. This was due on the one hand to the vagueness of the professional concept itself and on the other to the external pressures brought to bear on the occupation by the medical profession. It demanded a great deal of knowledge, ability, and willingness to work, yet little value was placed on a formalization of the job description” (Haider, 1997). Of course, there were training schemes, but these varied in length and quality and bore little comparison to the five years at least that medical training took. In the United Kingdom, formal registration for medical practitioners had begun in 1858. This led to a perceived need for a similar training and registration system for nurses, so, the Nursing Record asked for the whole question of the Registration of trained nurses to be set forth in a succinct form before the profession and the public (“The History of Self Regulation,” n.d.).

To conclude with, it is proved that it had been a slow process before the Hospitals Association had become committed to the idea of registration for nurses. The Matrons Committee, made up of the matrons of the leading hospitals, agreed, but could not agree as to a suitable length for training, one year or three. In 1887, the Hospitals Association established a non-statutory voluntary register. The Matrons Committee became more divided in their opinions split, between a group which supported the Hospitals Association and one year of training and those led by faction Ethel Bedford Fenwick, who were opposed the new register and sought rather extend training and to align themselves more closely with the medical profession. Florence Nightingale lent her support neither group, being opposed to any form of regulation for nursing, because she believed that the essential qualities of the nurse were something innate that could not be taught or examined and should not, therefore, be regulated. It is possible that if, at this early stage the Fenwick view had taken hold at this early stage nurse would have been placed somewhat higher up the medical hierarchy than they are. The newer professions such as physiotherapy, radiography, pharmacy have had, and are likely to continue to have a perceived higher status than nursing, simply because they came later and were considered to have a more scientific basis than ‘making the patient comfortable’ and yet that is ultimately the goal of any good nurse, trained and regulated or otherwise.


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Gaffney, R. (1982). “Women as doctors and nurses.” In O. Checkland & M. Lamb (Ed.), Healthcare as Social History. Aberdeen: Aberdeen University Press.

Nightingale, F. (1859). “Notes on Nursing.” The Natural Health Perspective. Retrieved from

“Nurse’s Duties in 1887”. (n.d.) Retrieved from:

Richmond, R. (1978). The Dictionary of Biographical Quotation. R. Kenin & J. Wintle (Eds.). NY: Dorset Press.

“The history of self-regulation.” (March, 2008). Nursing and Midwifery Council. Retrieved from

Woodham-Smith,C. (1978). The Dictionary of Biographical Quotation. R. Kenin & J. Wintle (Eds.). NY: Dorset Press.