The VNA of Boston story continues...

Rebecca writes:

We saw in the last post that Rathbone was able to overcome widespread skepticism that any good could come of trying to nurse the sick poor in their own homes when the conditions in these homes were so desperate. He successfully argued that the nurse’s efforts would result in longer lasting improvements if she addressed the environmental problems and the treatment would be less disruptive to the family and community if the patient could be nursed in place. However, there was a second difficulty – how to find enough trained nurses to meet the great need.

Florence Nightingale returned from the Crimean wars in 1856 a highly respected and famous woman. She widely promoted her beliefs about nursing as a profession, including the idea that nurses should receive rigorous training. The first modern nursing school was established at St Thomas’s Hospital in London with the first class of nurses starting in June of 1860. The curriculum was based on Nightingale’s vision of practical nursing skills learned at the bedside, the importance of creating a sanitary environment, the ability to observe the condition of the patient accurately and an emphasis on the strong moral character of the nurse. There was also a course of study including lectures on scientific and medical topics. These nurses were known as “Nightingale Nurses”. They represented a very different type of nurse from the untrained and sometimes unscrupulous women who had been serving as nurses in the poorest districts and the workhouses. The plan was for these trained nurses to establish more schools in hospitals around the country.

At this very time Rathbone was looking for trained nurses to staff his District Nursing organization in Liverpool and wrote to Nightingale in I861 asking how he could find suitable staff. Nightingale responded that it would not be possible to send any of her new nurses to work in Liverpool full time, but that she could send one to Liverpool to establish a training school in the Royal Infirmary. Thus it transpired that Rathbone also became closely involved in nursing training and in seeing that Nightingale’s vision was implemented in training programs throughout the country. This was the first contact in what became a life-long friendship with much correspondence and great mutual admiration between Nightingale and Rathbone based on their shared concern for the well-being of the poor and working classes of Great Britain. Rathbone wrote “in any matter of nursing Miss Nightingale is my Pope and I believe in her infallibility” and that he was “proud to be one of her journeymen workers”. At his death she wrote that he was “one of God’s best and greatest sons.”

In 1881 Florence Nightingale published a booklet entitled “Trained Nursing for the Sick Poor” reflecting on the progress that had been made in the 20 years since District Nursing had begun in Liverpool. The booklet was partly a plea for funding of national training programs with consistent standards and also for homes where district nurses could live together in order to develop an esprit de corps and where their meals and housekeeping would be taken care of, similar to what was provided for nurses who worked in hospitals. She also wrote about the unique nature of District Nursing.

“A District Nurse must first nurse. She 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. These district nurses – and it is the first time that it has ever been done - keep records of the patient’s state including pulse, temperature etc, for the doctor.”

“If a hospital must first of all be a place which shall do the sick no harm, how much more must the sick poor’s room be made a place not to render impossible recovery from the sickness which it has probably bred! This is what the London District Nurses do; they nurse the room as well as the patient, and teach the family to nurse the room.”

“A District Nurse must bring to the notice of the Officer of Health, or proper authority, sanitary defects, which he alone can remedy. Thus dustbins are emptied, water-butts cleaned, water supply and drainage examined and remedied, which looked as if this had not been done for one hundred years.”

“Hospitals are but an intermediate stage of civilization. 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.“

The next installment from Rebecca

Rebecca continues the story of the first Visiting Nurse Association:

As we saw in my last post, Rathbone and Robinson considered their 1859 experiment in district nursing to be an unqualified success. They could see that the efforts of the nurse resulted not only in a marked improvement in the health of the individual patient, but also in the well being of the entire family.

However, they faced skepticism from the medical and philanthropic communities when proposing the establishment of district nursing on a larger scale. Opposing groups argued the poor could already receive free medical help in hospitals and at free dispensaries. Those in the upper class, who were familiar with the living conditions of the poor, found it hard to believe that occasional visits from a trained nurse would make any real difference.  They contended that any help would be a short term gain, especially when the patient was still living in the dirty conditions of their crowded and busy homes.

True to the nature of his ancestors, William Rathbone VI stood by his conviction that this was a necessary and good plan and refused to be discouraged. He commented that “It is a work which is not immediately understood”. He offered four main arguments in support of district nursing: 

1) It is about chronic conditions

“There frequently occur cases of serious illness, which are either unsuited, or not admissible into general hospitals; cases for example of chronic disease combined with extreme poverty. Such are some classes of incurable diseases as cancer, consumption (in its later stages) and paralysis, bronchitis, rheumatism, ulcers, etc. and many diseases connected with confinements.”

2) Benefits of receiving care in the home

“The invalid often objects – or his family objects – to his removal from a place which, however wretched, is still a home. The comfort to the sick and to all the family which the nurse is able to give, the relief of knowing that the invalid need not be removed to the hospital, the restoration of order, the awakening of new hopes and the introduction of a more cheerful element – such are the happy results of the nurse’s work, which help to abate the bitterness, the feeling of having been abandoned by God and man, so deplorable and yet so natural in those, who, often without any fault of their own, find themselves plunged in inexpressible wretchedness.“

3) Limited resources at hospitals

“There are not, and there never can be, hospitals large enough and numerous enough to take in all cases of grave illness among the poor.”

4) Cost

“The work done by district nursing is, in proportion to its results, far less costly than that done by the hospitals. “

(Rathbone quoted from Annie Barinard’s 1922 book, The Evolution of Public Health Nursing)

As I read these arguments from over 150 years ago, I am struck by how Rathbone’s conception of the unique contributions and benefits of visiting nursing are still relevant today. In modern times we would also talk about prevention of illness and the reduction of avoidable hospitalizations, but these are simply extensions of the idea that visiting nursing is a sensible way to manage chronic conditions and to avoid expensive hospital stays. 

Rathbone also insisted on three main principles. First, that the work was not a work of charity and of temporary relief (which Rathbone and other reformers of the era felt would undermine the desire for self-reliance – what they termed pauperization), but of nursing and making a positive contribution to the long term well being of the person, the family and the community. Second, that the effort was to be independent of any religious motivation or influence, and lastly that the work is done by trained nurses. 

Rathbone was successful in finding the funds necessary to expand the program and within four years Liverpool was divided into 18 districts, of which all were provided with visiting nurses. Wealthy ladies contributed their time as Lady Superintendents to oversee the work and to ensure funding. They took on much responsibility, and would help manage the nurses’ time, consult on new cases, hear reports on old cases, promote the service to find new cases, arrange for the supply and distribution of medical comforts and appliances, maintain an inventory of necessary supplies and a record of their use, raise the money for the continuance of the work and keep financial records. Basically, they provided all the administrative functions of the modern organization.  These positions were highly coveted and were often handed down from mother to daughter. I imagine that the position provided purpose to the lives of women who would otherwise have few options for contributing to society and undertaking meaningful work. 

This was the organization Abbie Howes so admired on her trip to Liverpool in 1884 – and the one she successfully recreated in Boston in 1886 with help from her friend Phebe Adam and the Women’s Education Association. 

Next week I will write one last time about England in order to share how Florence Nightingale influenced William Rathbone and to summarize some of her thoughts on the development of District or Visiting Nursing.  

Continuing to tell our good story...