Issue No. 13 2006 — Making Badlands
When Ross Gibson wrote his Seven Versions of an Australian Badland, he was focusing on a geographical space. But the concept of a badland can be applied to other spaces, even virtual ones. Indeed, wherever one group struggles to dominate another and render that group as “untouchable” or “tainted”, the potential for a badland exists, especially if that struggle is depicted in terms of “good” and “evil” (Gibson). This paper explores such a space, that of the nursing bedside; where, from the late nineteenth century, trained nurses sought to take precedence over untrained nurses. What is interesting in this struggle, is the reliance of trained nurses on an early nineteenth century fictional image of an untrained nurse upon which to base their argument. Gibson suggests badlands are created in the minds of the players and are promoted by narrative. This will become evident in this examination of a badlands at the bedside, as trained nurses promoted an image of untrained nurses as threats to public safety. But how realistic was this image? To what extent were untrained nurses dangerous to their patients? To answer these questions, I will firstly outline who nineteenth century nurses were and why there was a need for one group to seek dominance. I will then consider the argument presented by trained nurses during the early years of the twentieth century and whether this argument is consistent with the available evidence. What will become evident is that the badlands associated with untrained nurses was largely created in the imaginations, and narratives, of trained nurses.
Until the nineteenth century, there were a number of people who carried out tasks that were described as nursing related, in a variety of settings. Then as now, there were members of the domestic household who tended family and friends. This group has traditionally drawn on women within the residence, particularly wives and daughters, although men also undertook this function, especially in the more isolated circumstances associated with rural and remote Australia (Madsen “Age of transition”). This group was not paid for their efforts. The second group of nurses was also generally unpaid: men and women of religious convictions, although women again dominated this group throughout the nineteenth and twentieth centuries (Nelson). The third group consisted of men and women who were inmates of institutions such as poor houses or, in Australia, prisons. These nurses had little choice in their occupation, and were generally assigned nursing duties because they were unfit for more labour-intensive work (Cushing, “Convicts and care giving” 120; Francis 173). A fourth group worked in hospitals and were provided board and lodging, such as it was, and a small wage or supply of alcohol (Helmstadter 334). In Australia, approximately half of this group consisted of men until the latter parts of the nineteenth century (Cushing, “Perspectives on male and female care giving” 264). Finally, nurses could be employed privately by patients and be attended to in their own homes: handywomen were generally associated with the working class while private duty nurses attended the gentry (Dingwall, Rafferty & Webster 7).
The most significant change that occurred within nursing during the nineteenth century was the emergence of another group of nurses: trained nurses. Initially these came from within religious orders, such as the Sisters of Charity. However, secular hospitals increasingly introduced nurse training. Thus, by the turn of the twentieth century, hospital nursing was dominated by women undertaking training, while private duty nursing was seen as the main avenue for these nurses once they had completed their training. Nursing transformed from something men and women did because they had little choice or from a sense of duty, to an increasingly competitive market between trained and untrained women. The problem for trained nurses was that the customer (or patient) was rarely able to differentiate between the trained and the untrained. With a tradition of so many groups of people who undertook skills associated with “nursing”, trained nurses needed to find a way of discrediting their competition. One of the means they drew upon was through exploiting some popular representations of untrained nurses, particularly those found within novels, as will be explored later.
It is worthwhile pointing out that the status of nursing during the late nineteenth century was extremely variable. Some untrained nurses had gained considerable nursing skill and knowledge through a number of informal avenues: experience, previous generations, contact with doctors, and through the increasing availability of home nursing manuals (Fenne 36). Other nurses, however, took up nursing with little or no preparation, aptitude or skill. Helmstadter’s research into the voluntary hospitals of London during the mid-nineteenth century highlights these variations in skill and knowledge as well as the moral status of nineteenth century nurses. Furthermore, because nursing was considered to be part of the domestic function of women, it did not stimulate much attention except when it was remiss. Thus, we have tended to have a skewed perception of nineteenth century nursing based on accounts provided by sanitary reformers of poor houses and public hospitals where there was a considerable lack of attention paid to the ill and incapacitated inmates by their fellow inmates acting in the role of the nurse (Digby and Steward). There is also documented evidence of nurses being brought before a magistrate for involvement with abortions (McIntosh), and there are statistics of high infant and maternal mortality rates (Mein Smith). Using such sources it would be relatively easy to paint a very bleak picture of nurses during the nineteenth century. It was this type of data trained nurses drew on to present themselves to doctors and the public as sanitary saviours, although they were not the sole custodians of sanitary reform.
In 1899 a group of doctors and trained nurses met in Sydney to form the Australasian Trained Nurses’ Association (ATNA), the first on-going professional nursing organisation in Australia (Strachan 30). One of the aims of this organisation was to protect and promote the interests of trained nurses over their untrained counterparts. Within the pages of the ATNA’s official journal, members reiterated their “right” to preferential treatment by doctors and the public, and condemned the untrained. Until the beginning of WWII, the ATNA in Queensland urged its members to distinguish themselves from the untrained through the use of badges, uniforms and veils.[1] One trained nurse wrote in 1907, “Would it not be possible for a Branch of the Australasian Trained Nurses’ Association to be formed in Perth, which would defend somewhat the Nurse outside the hospital, and which would enlighten the public generally on the treatment a Nurse might receive at its hands” (MATNA 119). There were also questions being asked as to whether untrained nurses could be stopped from practicing: “Can you let me know if there is any law prohibiting the practicing of the “Gamp” in midwifery” (Matron 313). The issue related to competition within the private duty market, but was frequently portrayed as a sanitary one:
At first I was only engaged by the better class of people, meeting with active opposition from the miner’s women folk, the “Sairey Gamp” of today being deemed all that was necessary for them. Being blessed with a good deal of obstinacy, not to say pig-headedness, I was determined that both classes should feel that trained nursing, with its attendant regard to strict asepsis, was necessary for all confinement cases, with the result that now “Mrs Gamp” in this place has to hustle for a good number of the cases she still gets. (Bellambi 380)
Gibson proposes that badlands are created in the minds of people so the unruly and unknown can be named and contained (178). One of the avenues trained nurses used to invoke a fear of untrained nurses within their communities and their profession was to draw on a fictional image: Mrs Sarah Gamp. By doing so, they were attempting to identify the unruly and to draw the boundaries around that which was deemed to be unsafe. That they should take this tack was probably not unintentional. Fenne points out that novels were closely aligned with the emerging British middle class in the nineteenth century. As such, a number of images of nurses would have been familiar to this group and they would have identified closely with these images because of nursing’s common domestic association. Indeed, we can find a number of fictional characters to represent the various nurses of the nineteenth century. Jane Austin portrayed examples of domestic nursing in Mrs Harville and Anne Elliot in Persuasion, while Mrs Rooke is an example of a privately hired nurse. Charlotte Bronte described another private nurse in Shirley, although Mrs Horsfall was depicted as a much rougher character than Mrs Rooke. A number of studies have been undertaken that investigate the fictional representations of nurses in Victorian novels (Maggs; Fenne; Judd). However, it was Sairey Gamp who captured the imagination of trained nurses who used her to construct the badlands at the bedside image. As such, it is worthwhile considering her in a little more detail.
Sairey Gamp is introduced about half way through the story of Martin Chuzzlewit, by Charles Dickens:
She was a fat old woman, this Mrs Gamp, with a husky voice and a moist eye, which she had a remarkable power of turning up, and only showing the white of it. Having very little neck, it cost her some trouble to look over herself, if one may say so, at those to whom she talked. She wore a very rusty black gown, rather the worse for snuff, and a shawl and bonnet to correspond. … The face of Mrs Gamp – the nose in particular – was somewhat red and swollen, and it was difficult to enjoy her society without becoming conscious of a smell of spirits. Like most persons who have attained to great eminence in their profession, she took to hers very kindly; insomuch, that setting aside her natural predilections as a woman, she went to a lying-in or a laying out with equal zest and relish. (310-11)
Gamp has a habit of relaying conversations she has had with Mrs Harris, who is a figment of her imagination. She is also very quick to ensure she would have a ready supply of liquor available throughout her term of employment, although stresses she does not drink much:
If it wasn’t for the nerve of a little sip of liquor give me (I never was able to do more than taste it), I could never go through with what I sometimes has to do. “Mrs Harris”, I says, at the very last case as ever I acted in, which it was but a young person, “Mrs Harris”, I says, “leave the bottle on the chimley-piece (sic), and don’t ask me to take none, but let me put my lips to it when I am so dispoged (sic), and then I will do what I’m engaged to do, according to the best of my ability. (Dickens 311)
Mrs Gamp is a close associate with the undertaker, and provides an example of moonlighting within nursing, when she is employed to attend a patient for 24 hours a day, but sneaks off to do a 12 hour night shift as well. Dickens’ description of Gamp during the beginning of this shift is insightful. First Sairey looks out the window to ensure she has a safe route of escape in the case of a fire, she tries the easy chair, looks over the medicine bottles, glasses and tea cups before finally taking a look at the patient, whereupon she places the patient’s arms by his side to see how he would look if laid out as a dead man. Her manner of nursing is also described. To administer medicine to the patient, she clutches his “windpipe”, and then removes his pillow to place on her easy chair, with the justification that, “Now he’s comfortable as much as I can be I’m sure” (Dickens 405).
It is easy to see how trained nurses would be able to demonise untrained nurses through association with such a figure and how the figure of the Gamp came to represent all that was contemptible in untrained nurses, and thus a badlands at the bedside. Dickens is noted for bringing his keen observations of life into his writing, often in an amusing although cutting manner. Indeed, the character of Sairey Gamp was based on a real nurse (Fenne 120). Although Martin Chuzzlewit was written a number of years before the introduction of trained nurses, Sairey Gamp provides us with an example of the handywoman and highlights the everyday, domestic nature of nursing as it existed in the nineteenth century. As indicated earlier, some of these women had gained informal nursing skill and knowledge. Others, however, would have been quite unprepared to take on such a role, and hence ineffective in their attendances. Unfortunately, necessity strikes the capable as well as the incapable, and in an era when women were severely limited in their paid employment options, nursing was often turned to as an acceptable means of income. Mrs Gamp was such a nurse, a woman with no formal skills, needing to earn her keep as best she could.
Interestingly, many of the letters of complaint generated from members of the ATNA came from regional and rural areas where there was a higher prevalence of untrained nurses. One such area was Central Queensland. While there is little doubt incapable nurses continued to exist into the twentieth century, one has to ask if Sairey Gamp represented all untrained nurses as trained nurses would have us believe and indeed, could the bedside provide Gibson with an eighth version of a badland? Was there substance to the badlands association or was it a convenient ploy by one group striving to dominate? Furthermore, one needs to ask in whose minds was the badland created – was it evident within the general public, or was it limited to trained nurses themselves? These questions are best addressed by considering one of the most controversial health aspects of the early twentieth century, that of puerperal fever. Moreover, focusing on a single geographical place where a large number of untrained nurses existed, such as Central Queensland, the site of Gibson’s badlands, these issues can be examined in more detail.
Puerperal fever was not the main cause of maternal morbidity or mortality, but it drew the greatest level of political and social attention because it was deemed as preventable from the late nineteenth century, and was linked to the lack of cleanliness by the birth attendant. Because of its infectious nature, it was a notifiable disease in Queensland. Table 1 illustrates the number of cases of puerperal fever in Queensland from 1901 – 1956.
Table 1: Total number of puerperal fever cases in Queensland, 1901 – 1956 (Solomon 75)
1901 |
1909-1910 |
1919-1920 |
1930 |
1940 |
1950 |
1954 |
1955 |
1956 |
10 |
11 |
26 |
40 |
33 |
2 |
8 |
29 |
23 |
What is clearly evident from this table is that there was an increase in puerperal fever post WWI. However, this was a time when untrained nurses were becoming less prevalent. In 1916 when lying-in hospitals were required to register with the Rockhampton City Council, eight of the nine nurse proprietors were untrained (Madsen “Nursing services in the Rockhampton district”; QNRB). All of these women registered as midwifery nurses with the Queensland Nurses’ Registration Board when it was established in 1912, indicating they had been nursing for some time.[2] Lying-in hospitals reached a peak during the early 1920s, but by the mid 1930s only one remained in Rockhampton (Madsen “Working from home” 51), and this was run by a trained nurse. Thus, by the early 1930s, most births were undertaken in larger hospitals, either public or privately owned, under the supervision of doctors and trained nurses, and yet the puerperal rate continued to rise. Furthermore, despite puerperal fever being a notifiable disease with significant sanctions associated with detection and the regular inspection of lying-in hospitals by the Medical Officer of Health, no record has been found of any cases of puerperal fever within Rockhampton’s lying-in hospitals among the available documents (from 1916 – 1930).
Similar rises in puerperal fever were evident in Victoria. Marshall-Allen’s 1928 report also indicated 90 percent of births were supervised by doctors. Marshall-Allen’s explanation of the increase in maternal morbidity associated with puerperal fever was the excessive use of artificial delivery and lack of aseptic technique by doctors (21-22). Despite this, Marshall-Allen recommended the elimination of untrained nurses from the midwifery bedside (23).
This examination of puerperal fever highlights two issues. The first is that the prevalence of untrained nurses had little impact on puerperal fever. Lack of asepsis, whether that be by untrained nurses or trained medical staff was the key to puerperal fever rates. The second is that despite the evidence, there was significant prejudice against untrained nurses suggesting the badlands concept of untrained nurses being unsafe was firmly in the minds of at least some medical staff by the 1920s, but perhaps not all, as the lying-in hospitals run by untrained nurses in Rockhampton did not operate in isolation of doctors (Madsen “Working from home” 59). Furthermore, the Rockhampton data indicates women continued to seek the services of untrained nurses throughout the 1920s, and that the reasons for lying-in hospitals closing related to economic circumstances and the age of the proprietors, not to unsafe practices (Madsen “Working from home” 59-62).
The data relating to untrained nurses in Rockhampton contributes to a growing argument over the past decade or so that untrained nurses continued to be quite prevalent well into the twentieth century and that their presence did not pose a significant health threat to the general public (Summers; Mortimer; Martyr). Such evidence suggests that it was trained nurses and professional nursing associations who created the image of untrained nurses as a badlands at the bedside. Undoubtedly, incompetent nurses existed in the nineteenth century, and continued to exist during the early part of the twentieth century, but it was the manner in which professional trained nursing associations portrayed all untrained nurses as incompetent and a danger to the community that is interesting and probably not a reflection of reality. Indeed, the community and even the government appear to have supported untrained nurses in a variety of clinical settings. For example, lying-in hospitals owned and managed by untrained nurses provided the majority of maternity beds in Rockhampton until the late 1920s (Madsen “Nursing services in the Rockhampton district”). Furthermore, government run facilities such as Westwood Sanatorium were mostly staffed by untrained nurses, albeit under the supervision of a small number of trained nurses (Madsen “Nursing services in the Rockhampton district”). Small hospitals also used untrained staff supervised by one or two trained nurses. Moreover, some of these staff became so valuable, their hospitals’ managing committees wanted to pay them as staff nurses (QATNA minutes). Edwards also notes that aged care facilities in Britain have relied heavily on untrained nurses throughout the twentieth century. Thus, the skills and knowledge of untrained nurses were not universally called into question. Rather, the rhetoric coming from professional nursing associations reflected the social and political stances of an elite group within nursing – including those of the executive committee who were from large metropolitan training hospitals where untrained nurses were not permitted. It was these nurses who were pushing the untrained = unsafe agenda as a means of promoting nursing’s professional aspirations and thus their own social positions.
To a certain extent, Charles Dickens created the badlands at the bedside image in 1844, based on a characterization of handywomen during a time when trained nurses did not exist. It was not the only representation of nurses within Victorian literature, but it came to symbolize all that was undesirable in a nurse. As nursing came to be particularly associated with a more limited group, that of trained nurses, so the image came to be associated with those who sat outside that group. This paper has explored this image: its origins, its reflection of reality and the way it was used by one group of nurses to exclude another. Interestingly, Sairey Gamp was remonstrated by Martin Chuzzlewit for her selfishness and disinterest in her patients (Dickens 786), not her ineffectiveness as a nurse. Ironically, it seems that self-interest was a prime motivating factor behind the campaign against “Gamps” by trained nurses.
Endnotes
Wendy Madsen has been researching the history of nursing in Central Queensland for the past decade, including masters and recently completed doctoral studies. She is interested in how nursing practice evolved during the first half of the twentieth century in response to factors internal to the profession as well as those external to nursing. w.madsen@cqu.edu.au
[1] Queensland branch ATNA minutes The Australasian Nurses’ Association Journal 15 May 1933, p. 97; Annual General Meeting QATNA The Australasian Nurses’ Association Journal 15 August 1933, p. 167; AGM QATNA minutes The Australasian Nurses’ Association Journal 15 August 1934, p. 177; QATNA minutes The Australasian Nurses’ Association Journal 15 September 1936, p. 172; QATNA minutes The Australasian Nurses’ Association Journal 15 December 1938, p. 255
[2] In order for untrained nurses to register with the Queensland Nurses’ Registration Board, they had to demonstrate they had been working as a nurse for at least the previous three years (Health Act Amendment Act 1911). This provision to allow formally untrained nurses entry to the register was closed within a few years.
Works Cited
Austin, Jane. Persuasion. Hertfordshire:Wordsworth Classics, 1996.
Bellambi. Letter to Editor. The Australasian Nurses’ Association Journal 5.12 (1907): 379-381.
Bronte, Charlotte. Shirley. Hertfordshire:Wordsworth Classics, 1993.
Cushing, Angela. “Perspectives on male and female care giving in Victoria, 1850 – 1890.” New countries and old medicine. Proceedings of an International conference on the history of medicine and health. Eds. Linda Bryder, Derek A. Dow. Auckland: The Auckland Medical Historical Society, 1995. 263-270.
Cushing, Angela. “Convicts and care giving in colonial Australia, 1788 – 1868.” Nursing History and the Politics of Welfare. Eds. Anne-Marie Rafferty, Jane Robinson, Ruth Elkan. London: Routledge, 1997. 108-132.
Dickens, Charles. Martin Chuzzlewit, London: Collins Clear-type Press, n.d.
Digby, Anne, & John Steward. Gender, health and welfare. London: Routledge, 1996.
Dingwall, Robert, Anne Marie Rafferty & Charles Webster. An Introduction to the Social History of Nursing. London: Routledge, 1988.
Edwards, Margaret. “The nurses’ aide: past and future necessity.” Journal of Advanced Nursing 26 (1997):237-245.
Fenne, Jennifer. “‘Every woman is a nurse’: domestic nurses in nineteenth century English popular literature.” Diss. University of Wisconsin-Madison, 2000.
Francis, Karen. “Service to the poor: the foundations of community nursing in England, Ireland and New South Wales.” International Journal of Nursing Practice 7 (2001): 169-176.
Gibson, Ross. Seven Versions of an Australian Badland. St Lucia: University of Queensland Press, 2002.
Grehan, Madonna. “From the sphere of Sarah Gampism: the professionalisation of nursing and midwifery in the Colony of Victoria.” Nursing Inquiry 11.3 (2004): 192-201.
Helmstadter, Carol. “Early nursing reform in nineteenth-century London: a doctor-driven phenomenon.” Medical History, 46.3 (2002): 161-197.
Judd, Catherine. Bedside seductions: Nursing and the Victorian imagination 1830 – 1880. New York: St Martins, 1998.
Madsen, Wendy. “The age of transition: nursing and caring in the nineteenth century.” Journal of Australian Studies 78 (2003): 39-45.
Madsen, Wendy. “Working from home: lying-in hospitals of Rockhampton, 1916-30.” Health and History 7.1 (2005): 49-66.
Madsen, Wendy. “Nursing Services in the Rockhampton District.” Diss. Queensland University of Technology, 2005.
Maggs, Christopher. The Origins of General Nursing. London: Croom Helm, 1983.
Martyr, Phillipa. Paradise of Quacks. An Alternative History of Medicine in Australia. Sydney: Macleay Press, 2002.
Marshall Allen, Robert. Report on Maternal Mortality and Morbidity in the State of Victoria, Australia. Melbourne: University of Melbourne, 1928.
MATNA. Letter to Editor. The Australasian Nurses’ Association Journal 5.4 (1907): 119-120.
Matron. Letter to Editor. The Australasian Nurses’ Association Journal 5.10 (1907): 313.
McIntosh, Tania. “An abortionist city: maternal mortality, abortion and birth control in Sheffield 1920 – 1940.” Medical History 44.1 (2000): 75-96.
Mein Smith, Phillipa. Mothers and King baby. Infant survival and welfare in an imperial world: Australia 1880 – 1950. Hampshire: Macmillan Press, 1997.
Mortimer, Barbara. “Independent women: domiciliary nurses in mid nineteenth century Edinburgh.” Nursing History and the Politics of Welfare. Eds. Anne-Marie Rafferty, Jane Robinson, Ruth Elkan. London: Routledge, 1997. 133-149.
Nelson, Sioban. Say little, do much. Nurses, nuns and hospitals in the nineteenth century. Philadelphia: University of Philadelphia Press, 2001.
Queensland branch of Australasian Trained Nurses’ Association minutes, 10 March 1943, Queensland Nurses’ Union, Brisbane.
Queensland Nurses Registration Board (QNRB). Register of Midwifery Nurses 1912 – 1925. Queensland State Archives, Brisbane. File A/73218.
Solomon, S.E. Queensland Year Book 1957. Brisbane: Government Printer, 1957.
Strachan, Glenda. Labour of Love. The History of the Nurses’ Association in Queensland 1860 – 1950. St Leonards: Allen & Unwin, 1996.
Summers, Annette. “Sairey Gamp: generating fact from fiction.” Nursing Inquiry 4 (1997): 14-18.