| Janet Hargreaves, University of Huddersfield (retired) | The UKAHN Bulletin |
| Volume 10 (1) 2022 | |
Introduction
Nursing homes are ubiquitous.[2] It is difficult to walk more than a mile in an urban environment in Britain without passing one. Old, converted houses and purpose-built dwellings; large semi-institutions and quasi luxury hotels all offer accommodation combined with various levels of sanctuary and care, usually for a fee. They appeared as a recognisable health sector in the late nineteenth century: the use of the term ‘home’, rather than hospital, clinic or sanatorium, implying a setting with the comforts and appearance of home, whilst, when required, providing nursing, midwifery or medical care. At their best, this is exactly what they are. However, throughout their history, they have become a source of scandal and enquiry; most recently as a result of excess deaths during the Covid 19 pandemic.[3]
This article chronicles the development of the nursing home sector from its emergence in the mid-nineteenth century to the 1930s, a decade after it was definitively regulated by the 1927 Nursing Home Registration Act. Sources include published research, Parliamentary papers, in particular the Select Committee reports from 1905 and 1926, debates in parliament, and contemporary newspaper articles. In addition, a detailed autobiographical account of one nurse’s experience of nursing home work from 1932 -1937, offers an illustrative case study.
Nurses and nursing homes
Two closely linked nineteenth-century developments underpin the emergence of the nursing home sector. These relate to the nurses themselves and the establishments that increasingly became a location for their practice.
Private and Independent Nurses
In the nineteenth century, the number of nurses with some level of training grew proportionately driven by the growth in the number of hospitals and hospital beds but hospital nurses were not the only type of nurse to be found. Dingwall et al suggest that the majority of nursing care occurred in people’s own homes provided by family members, servants or hired private nurses.[4] Examples of this in literature include Jane Austen’s novel Persuasion, set in the early nineteenth century, in which Anne Elliot, the unmarried daughter of the family is frequently called upon to nurse sick relatives and nurse Rooke is hired to care for her friend. Austen’s analysis of the world through the lens of ordinary life testifies to these practises being commonplace for the wealthy and middle-classes.[5] Furthermore Alannah Tomkins’ exploration of diaries and other writing from three women at the end of the eighteenth century shows glimpses of the employment, paid or otherwise, of actual women in a recognisably nursing role.[6]
Even as the institutionalisation of care gained traction throughout the century the majority of people in receipt of nursing care were still in non-institutional settings. In her research into private nurses in Edinburgh, Barbara Mortimer states:
The possibility that one of that shadowy group of women, the early nineteenth century domiciliary nurses, could be viewed as a successful business woman is perhaps surprising, but the increasingly wealthy, sophisticated and leisured middle classes of the first half of the nineteenth century generated a demand for their services … [but such a nurse] is the most elusive of creatures.[7]
Mortimer sought to address their invisibility by interrogating Post Office directories and census data for Edinburgh in the second half of the nineteenth century, looking for people identifying as ‘nurse, not domestic servant’. She identified a cohort of women who worked as private or domiciliary nurses either during and after childbirth or a period of sickness. Their nursing took place either in their patient’s own homes or in a lodging house or hotel, as Edinburgh was a prestigious medical centre which people would visit for a consultation and treatment.[8]
The nurses Mortimer identified were single or widowed women, in their thirties upwards: most (although not all) renting single room accommodation, or returning to lodge with an adult child when they were not living on a job. Mortimer found that the residences of many of the nurses clustered in the same streets and even several in the same house, suggesting an informal network of mutual support in terms of shared rent, but also reciprocal arrangements where nurses, and doctors, might recommend each other.[9]
Throughout the nineteenth and early twentieth centuries the demand for private nursing outpaced supply, making this a lucrative venture for individual nurses, agencies and hospitals. Thus, in parallel with the growth of the health sector in general, Mortimer’s informal networks appear to have grown into more organised, bureaucratic associations providing private nursing, in the patients’ home and in bespoke nursing and convalescent homes. Early twentieth-century journalist Sarah Tooley, writing in 1906, suggested that 66 per cent of trained nurses moved out of hospitals to work. They had two options; to work alone, building their networks much as described by Mortimer, or to join a nursing association, cooperative or agency.[10] A study of nursing at St Georges hospital in London in the late nineteenth century, suggests that private nursing accounted for 30-40% of each cohort of newly-qualified nurses’ follow-on employment.[11]
Stuart Wildman has examined the growth of nursing associations, showing that nursing reform happened in community and provincial settings, not just in city-centre teaching hospitals. He identifies that by 1900 there were at least fifty-seven local nursing associations in England providing community and private nurses. [12]
For the client, the nursing associations acted as an agency, charging a fee which covered the nurse’s salary and operational costs. At their best they provided the nurse with a respectable home, a bed to return to and a postal address. Some associations were overtly philanthropic, for example the Cottage Benefit Nursing Association, established in the south of England in 1882. This pioneered what became known as the ‘Holt-Ockley’ model, which recognised that in poorer families, illness had consequences for the whole family so a hybrid nurse/home help lived in with a family through a time of need.[13] At their worst, associations and agencies were purely for profit and gained a reputation for exploiting nurses and patients by underpaying the nurses, providing no guarantees of quality to patients and charging extortionate fees.
In addition to the camaraderie and support of their peers, the best associations employed a well-bred superintendent who modelled and cultivated within the nurses the manners and behaviour that would make them acceptable in wealthy private homes. Some associations even took on women and paid for their training. In this regard they acted as an alternative to hospital nursing.[14] The London Hospital, the largest voluntary hospital of its time, pioneered the creation of in-house private agencies utilising their existing infrastructure of nurse training and accommodation. Doctors working in voluntary hospitals (often for no salary, but in exchange for research, training and career enhancement) could call upon ‘his’ hospital to provide nurses for his private practice patients. By working together in this way, the reputation of the hospital, and the doctor, were enhanced, and the profits from private nursing fees (the hospital charged a premium for their services) were much needed additional income.[15]
Although agency terms could be exploitative, for an unmarried nurse they offered a stable and respectable base to work from. There was also the opportunity to gain an individual reputation and move into freelance private nursing, or to be offered a permanent post with a wealthy family or nursing home. Patronage might also play a part: the physician Lord Dawson of Penn built his prestigious reputation at The London Hospital, becoming physician to the King George V and developing a lucrative private practice. Nurses from The London were frequently called upon to nurse his patients: for example Nurse Black, after being selected to nurse the King George V, moved to a permanent post with the Royal Family up to his death.[16]
Hawkins suggests that for nurses who could be independent, private nursing was a good option: ‘it offered better wages, freedom from institutional life, the choice of when to work and the opportunity to be one’s own boss. For nurses with children, it offered flexibility and the chance to return to the family home’. However, there were no paid holidays, no free health care or paid sick leave, and although wages could be higher there were many hidden costs, not least having to manage financially between periods of employment. Hawkins also suggests that independent nursing could carry potential dangers: ‘Working within private homes, a nurse was frequently exposed to intimate but unchaperoned contact with the opposite sex in a way very few other domestic workers were and, in an environment very different from that in hospitals’.[17]
The ‘danger’ of unchaperoned contact could also, of course, create an opportunity for a role that started as nursing to grow into longer-term companionship, or romance. Linda Kearns, writing about her experience of nursing in Ireland in the early twentieth century, recalls that she was given the significant legacy of a motor car by her long-term private patient when he died.[18]
Whilst there had been significant change regarding the training and management of non-hospital nursing since Mortimer’s findings, in the late nineteenth century private and independent nursing remained a significant occupational subsection of the nursing profession.
The birth of nursing homes
The location of nursing and nursing care also continued to change. By the end of the nineteenth century the number and range of institutions included voluntary, cottage and maternity hospitals, asylums for those considered mentally ill, tuberculosis sanatoria and fever hospitals, as well as public and local authority hospitals; all with various funding models and different functions. The largest concentration of institutionalised sick people was in workhouses, where the impoverished sick or chronically ill, were obliged to accept the only care available to them.[19] People with the means to do so, were willing to pay for privacy so private hospital wings developed in voluntary and cottage hospitals, which met some of the need for acute episodes of care. Longer term illness was more difficult and even those with very little money to spare, might strive to find a solution to caring for a chronically sick, mentally ill or frail relative in some way that avoided mixing with the sick poor or the stigma of the lunatic asylum and workhouse.
From this vacuum of need emerged a hugely diverse, largely for profit, unregulated ‘nursing home’ sector. Quite literally anyone could set up, advertise and run a nursing home. They may best be described by the preamble to the 1926 Report from the Select Committee on Nursing Homes (Registration):
[T]hroughout the country there are many institutions (the actual number could not be ascertained) of very different kinds, both as regards to the type of patient catered for and the nature of the building occupied; under various conditions of ownership and management, carried on mainly or entirely for purposes of gain; and grading almost imperceptible at one end into the lodging house, and at the other into the large public hospital; but which, taken together, may be regarded as forming a legitimate industry meeting definite needs.[20]
When the nursing home, as a recognisable ‘legitimate industry’, was established is difficult to pinpoint. In Mortimer’s Edinburgh-based research there is no mention of any organised nursing homes in which her nurses worked; her data mostly goes as far as the 1871 census. Tooley cites 1872 as the origin of the Royal Scottish Nursing Association, which provided nurses and nursing homes, suggesting that change was on the way.[21] Certainly, by the 1880s nursing homes, nursing associations and agencies advertise for staff and patients in the press and in nursing journals, suggesting that they are becoming widespread. This may be illustrated by the London Post Office directories where there is no mention of ‘nursing or convalescent home’ in the 1841 and 1852 directories but by 1882 there are at least twenty-two listed. The largest were ambitious, well-run enterprises, providing nurses and a range of nursing homes, as can be seen in this advertisement placed by the London Association of Nurses, claimed by Tooley to be the pioneer of the cooperative nursing movement:
Superior Hospital trained nurses; for medical, mental, monthly, surgical, fever & small pox cases, are always in readiness; also male attendants and medical rubbers. In this association the nurses are not paid by small salaries, but receive their earnings. In connection with the above there are several home hospitals where patients can be received under the care of their own doctor and a country convalescent home for patients recovering from scarlet fever.[22]
This unfettered industry provided opportunities and risks for all concerned. Some of the issues are aired in a Nursing Record editorial of 1895, which calculates the financial benefit to a patient staying in a hotel and privately employing two nurses against nursing home admission. The latter can provide: ‘the richer classes with the advantages of hospital treatment in the shape of skilled nursing and regulated dietary (sic), combined with the comforts and refinements of a private house … to have ready at hand every necessary appliance, at a greatly reduced cost’. However, in line with the journal’s known support for registration, it goes on to say that many nursing homes are no more than lodging houses run by people with no nurse training, many of which make a good profit, but ultimately are found to provide poor or dangerous care. Tooley reiterates the point in 1906, stating that well run establishments will vet, and expel poor quality nurses but that there is nothing to control the unsatisfactory nurse who ‘gravitates to a third-rate association, to some fraud on the public in the shape of a nursing home’.[23]
Interest was not confined to the nursing press. John Bull, a London-based weekly magazine with popular mass appeal, claiming according to its owner at the time, Horatio Bottomley, to ‘uphold the interests of the common man’, presented a more journalistic view.[24] In 1910, the magazine ran a campaign over several months under the headline ‘“Nursing Homes” Or -?’ in which their ‘special commissioner’ reported on ‘Bogus Nursing Homes and Massage Establishments’. Their investigation centred on nurses and genuine businesses being smeared by the title ‘nurse’ or ‘masseuse’ being used as a cover for sex work. They also uncovered instances of patients being cheated and robbed, young women being entrapped and alliances between nurses and undertakers to mutually benefit by a patient’s death.[25]
Thus, from around the 1880s, nursing homes were a well-recognised phenomena which received negative scrutiny in nursing journals and the popular press. A lack of agreed standards and regulation of the title ‘nurse’, and of nursing homes, led to dangers for nurses and patients, as well as reputational damage for legitimate, well-run businesses. Neither fee levels nor recommendations were a guarantee of quality: once a patient entered a nursing home, they could be given substandard care, be exploited and effectively be imprisoned. The need for some form of legislation was clear, but what, and how to administer it, took over 40 years to resolve.
Regulating Nursing Homes
The human cost to public health of the strongly defended political belief that British society was best served by an unimpeded capitalist economy, is well documented.[26] The key legislation arising from public campaigns and political scrutiny of human misery, relevant to nursing homes, firstly includes sanitary reform. The 1848 Public Health Act and following 1866 Sanitary Act set standards for the infrastructure of buildings, including the supply of adequate water and the removal of waste. From 1866 sanitary inspectors needed to pass a building as fit for habitation. Although this was still far from perfect, improvements in housing structure, sanitation and the supply of clean water with concomitant reduction in epidemics such a cholera, did follow.[27]
Regulating the care and containment of people with mental illness and ‘deficiency’ had been ongoing throughout the nineteenth century and was revisited in a Royal Commission of 1908 which culminated in the Mental Deficiency Act of 1913. This created a Board of Control to supervise local authorities in running ‘mental deficiency’ services and to inspect premises.[28] In parallel, campaigning due to high infant mortality and maternal puerperal fever, led to Select Committee reports in 1892 and 1893 and the Midwives Act of 1902, which set out the training, registration and supervision of midwives. Births now had to be supervised by a registered midwife or doctor, and there was some scrutiny of maternity homes.[29] However, this was not comprehensive, and many ‘nursing’ homes would take any paying patient, from the chronically sick to ‘lying in’ women.
Thus, by the early twentieth century, mental deficiency nursing homes and some maternity homes were subject to legislation and inspection. However, the first attempt to properly investigate the nursing home sector in its entirety was the 1905 Select Committee on the Registration of Nurses. Thirty-four witnesses were called to give evidence on a range of nursing issues which they argued were interrelated: the registration of individual nurses, and of training schools for nurses; the licensing of homes charging for nursing care; and of institutions and societies which supplied or employed nurses for gain. The committee concluded that the overarching concern was that it was impossible to know if the person calling him or herself ‘nurse’ was adequately trained to offer the service provided and that the potential for exploitation and fraud by the individuals and organisations involved were sufficiently serious to require a system for regulation. [30]
The Committee’s recommendations, including the registration of nurses, regulation of nursing schools, nursing institutions and nursing homes, were not universally accepted by nurses and their representatives. Due to this disagreement, and the 1914-18 war, it was fourteen years before the Nurse Registration Act in 1919 was passed and over twenty before a further Select Committee specifically scrutinising nursing homes was formed.[31]
This second Select Committee [Figure 1] had the advantage of nurses and midwives being now registered, and first-hand experience of mental deficiency and maternity home inspection. It was appointed on 2 March 1926 with a much tighter brief: ‘to consider and inquire into the question of the inspection and supervision of nursing homes in order to report on any legislation that might be “necessary or desirable”.’[32]
Over four months, fourteen meetings were held and thirty-six witnesses heard: these comprehensively included representation of nurses and doctors, Medical Officers of Health (MoH), people running nursing homes, lay visitors, staff and patients. The complexity and detail of the report is too great to explore fully in this paper, illustrating as it does, the huge difficulties of regulating an amorphous industry where the human needs of staff and patients must be balanced against a for-profit business model. Testimony may be summarised under three broad categories: types of patients; quality and cost of care; and competing demands.
The types of care provided covered almost the full gamut of health care: medical and surgical patients who might equally be found in an acute hospital, but were paying for the privacy and seclusion of a home versus an open, public ward; maternity cases; the senile, the frail and chronically ill; and the convalescent. Many nursing homes accommodated all five categories. Representations from groups such as Christian Scientists, added a dimension by introducing situations that defied conventional description.
In terms of quality and cost of care, numerous witnesses petitioned the committee with individual examples of fraudulent or dangerous practice, poor care and neglect. These were summed up in the report’s findings to parliament:
Patients, particularly of the senile type, are stated to be left entirely to administer to their own wants although often quite incapable of doing so … they frequently develop bed sores due to prolonged neglect. They are rarely washed. The bed linen is changed at infrequent intervals, even when soiled. The rooms are verminous. No adequate protection is taken to prevent dissemination of contagious or infectious diseases, and frequently patients are unable to obtain any assistance when they require it. The food is scanty and often quite unsuitable and has to be supplemented by the patients themselves or their friends. Elderly and senile patients, practically put away in a cheap home by relatives who take little or no further interest in them, suffer great indignities, are very unhappy and too frightened to make any complaint. In one case no proper provision was made for the removal of a patient, who had died, from the room in which other patients were still accommodated.[33]
Although cost was a factor, it was not a straightforward indicator of quality. Whilst some witnesses felt that wealthy patients could buy quality, others cited examples where care was poor despite high fees. Doctor Lyster represented the Society of MoH stating: ‘Every MoH is always receiving complaints … first the scarcity of nursing homes at a moderate price, and secondly the unsatisfactory character of some nursing homes at all prices.’ He goes on to explain the issues with supply, demand and cost: ‘there is a very serious deficiency for people of the class who will not use the poor law infirmary and have no opportunity of getting into a voluntary hospital’.[34]
The panel routinely asked witnesses for their opinion on a reasonable fee, and whilst this varied, the consensus was that between three and five pounds per week was needed to provide a comfortable and caring environment (before additional fees for doctors’ consultations and specialist nursing), however, many homes charged much less than this. Mr Anderson, a vicar who visited parishioners in nursing homes described poor, bed ridden people paying very low fees of fifteen to twenty-five shillings per week for awful conditions.[35]
Doctor Menzies, MoH in London, was interviewed because of his experience in inspecting maternity homes, making him uniquely qualified to comment. He suggested that there was a three-tier system, which was endorsed by other witnesses: The first two tiers were homes directly attached to a hospital or owned and run by a doctor or nurse with close ties to hospitals. Both were well run but when in a converted house they did not have the infrastructure to properly support medical and surgical care; for example, other testimonies talk of post operative patients having to be carried up and down steep narrow staircases. Patients using these homes were often paying fees at the higher end for the privacy and exclusivity of the nursing home but with a standard of care and safety lower than in a hospital. He identified his third tier as homes for the chronically ill who were not ill enough for a poor law hospital bed, trying to avoid the workhouse and budgeting for no more than one pound per week. Thus, they were especially vulnerable to the very lowest standard in the for-profit sector. He passionately offered an argument for more paying beds in hospitals and for systematic, organised, not for profit institutions, presaging the NHS and local authority infrastructures actioned later in the century.[36]
Teasing out the significance of the many competing demands, further illustrated the diversity of practice. Doctors argued strongly that their very presence rendered inspection unnecessary, as their own registration safeguarded against abuses. This applied to doctors who owned or worked closely with a particular home as well as those who let a small number of rooms in their own home to paying ‘guests’. The committee summed up this latter group as:
Doctors [who] take in single patients for treatment in their private houses; frequently such cases require no actual nursing but merely normal home life and the sympathetic companionship of intelligent persons. It is submitted by certain witnesses that the term “nursing home” cannot properly be applied to cases of this type and that registration is not required.[37]
The medical profession argued that it would be sufficient to have a list of such homes where two doctors signed to attest to the suitability of the doctor in charge. There was overwhelming evidence to the committee that countered the doctors’ claims and made their suggestions untenable. Patients freely admitted being too afraid to speak out, so doctors did not know what was happening. One witness, Miss Dora Vine, a patient who was herself a nurse and midwife asked for her doctor’s help, but he had no authority to intervene and she did not have sufficient money to leave and go elsewhere.[38]
Female proprietors, nurses and the representatives of the nursing profession strongly supported registration and inspection of the homes. They saw it as safeguarding their own professionalism by exposing poor practice. There was a fair consensus that some nursing homes, as reported in the Nursing Record, were in effect former lodging houses where the owner, with no qualifications and little nursing experience renamed their establishment a nursing home so that a greater profit could be made from each room.[39] However, there were many caveats: they would have liked a two-tier system where ‘better’ homes – such as their own – had less scrutiny than others, but they could not say how this would be established or managed. They said that they wanted no ‘brass plaque’ or other visible signs as patients came to them precisely because they looked like a normal, well-appointed house and that this discretion was part of the package. Also, regarding privacy, they were adamant, and in this were united with the doctors, that patients’ cases and personal details could never be part of the inspection. In some cases, this might be an unwanted pregnancy, and as can been seen in the case study below, patients might also present with conditions such as alcoholism or sexually transmitted diseases that they would not want known.
The most unusual group who presented evidence to the Committee proved to be the Christian Scientists: accommodating their demands without creating a dangerous loophole was challenging. In a prepared statement, their representative Mr Tennant stated:
In the practice of Christian Science there is nothing secret, nor are there any facts which we have to conceal, but the great objection which we would have to a system of registration would be the consequent inspection involving supervision and control by a body of persons who do not understand the practice of Christian Science … It is this lack of knowledge and understanding of our methods which arouse suspicion and cause distrust, and we maintain that there is no reason why we should be subject to the prejudice and opposition arising therefrom. We have therefore a very strong objection to anything that involves the inspection or visits paid with a view to criticising or supervising or controlling our methods.[40]
He added that they catered for ‘nerve cases, all kinds of sickness and moral cases’ but could not further define this, other than illness is the physical manifestation of sin. He admitted that he had no idea how many homes they were running in England, and that people within the movement who were thought to have a gift for spiritual healing also took individual patients into their own homes. The nurses running the homes were said to be trained in Christian Science methods in Boston, USA, and could ‘handle a sick person perfectly’ but were not registered as nurses in England, which for the committee became a fundamental tenet for inspection. However, their concession was that they were happy for the premises to be inspected for suitability, as long as patients were not scrutinised. In this regard they actually had much in common with the more conventional lobbying groups.
Reaching consensus
Having established a compelling need for legislation, and having rejected doctors’ requests to be treated differently, the committee explored what and how to achieve consensus on the way forward. Excluding patients’ details was unanimously accepted; beyond that there remained the infrastructure and ongoing maintenance of the building and equipment, the quantity and quality of staff, and the ways in which both patients and staff were treated. They recommended that this should be managed at county or borough council level, trying to strike a balance between being too central and unwieldly, or too local, as fears were raised that inspectors, too close to their community, might be resented, might show favouritism or might gossip about patients they had seen.[41]
Whilst the overall need for legislation was not at risk of being ignored, as it had been in 1905, criticism did continue. In the second reading in the House of Lords, Lord Dawson of Penn, one of the witnesses to the select committee, reiterated the medical profession’s objections to inspection:
My Lords, I agree … that there is by no means a universal approval of this Bill. On the contrary, there is considerable divergence of opinion … To my mind, the sole justification for the Bill is that the Committee of the House of Commons did disclose very serious abuses which had occurred in certain nursing homes in various parts of the country. [However, he continues:] … I look from a professional point of view with considerable scepticism on the idea that you are going to improve them by any system of inspection … The drafting of the Bill is such that it gives powers of a most extensive character, and unless those powers are used with great discretion, they might lead to an intolerable tyranny … you will get that pettifogging form of inspection which does harm rather than good.[42]
Notwithstanding this, the report was accepted by parliament and with minor amendments, became law in 1927.
Molly Murphy – A case study
Reports and legislation provide one view of nursing homes and the way they were expected to work. Personal testimony provides another. My case study of a nursing home nurse focusses on a remarkable woman, Molly Murphy, who was both a nurse and an activist in the interwar years and into the Second World War.[43]
Molly Murphy’s first-hand account of working as a nurse in a nursing home in the 1930s reflects much already discussed in this article, and offers a much more detailed account than those contained within the Select Committee Report, and illustrates the potential for an enriching career. Her memoir, which she titled ‘Nurse Molly’ was discovered by happenstance. Written in the early 1960s, when she and husband Jack were towards the end of their lives, it consists of a typewritten manuscript. After Molly’s death in 1964 Jack tried but failed to get a publisher. Over thirty years later, Ralph Darlington whilst researching a biography of Jack Murphy, travelled to Canada to interview Gordon Murphy, their son, who had emigrated there after World War Two. In addition to Jack’s papers, Gordon shared the memoir, and the handwritten letters that survived from Molly’s nursing during the Spanish Civil War. Darlington was able to bring these back to England and deposited them in the archives of what is now the People’s History Museum in Salford. In 1998 he published an edited version ‘Molly Murphy, Suffragette and Socialist’.[44] From the perspective of nursing history, Molly’s memoire offers detailed accounts of her training and early career between 1915 and 1920; her experience as a nurse in a nursing home in 1932-1937; and nursing during conflict in the Spanish Civil War and in London during World War Two 1937-1942. This case study draws on Molly’s papers as they relate to her experience as a nursing home nurse.
In 1932, five years after the Nursing Home Act was passed, forty-two-year-old Molly Murphy [Figure 2] a wife and mother, faced a crisis point in her life. Her husband’s resignation from a senior role in the Communist Party of Great Britain led to their loss of family income.[45] Faced with no money to live on and school fees for their son, Molly, mirroring her mother in the 1890s, seized the opportunity to work, returning to nursing.[46] Molly had qualified in 1919, prior to the Nurse Registration Act being in place but claimed her registration in 1923, suggesting she had hoped to return to her career. Her choice of a nursing home, rather than a hospital, as her point of return, allowed her to choose her hours of work and maintain her social position at home. She states in her memoir: ‘When I walked through the nursing home district in the West End of London, I saw a big nursing home in front of me and the idea flashed through my mind ‘why not go straight in and interview the matron?’’.[47] Offered a shift that night, she purchased a uniform and returned. Jack recalls: ‘I came home late one night after I had been unsuccessfully searching for work and found a note on the table. It said: “Gone to work. See you in the morning. Love. Molly”. Without saying a word to me of her intention, she had become a nurse again and the main support of our home’.[48] What followed was five years of surprisingly rich nursing work, full of professional respect, independence and variety.
Molly was unimpressed with the integrity of the first home, where she discovered a more experienced nurse had been dismissed in order to engage her on a lower rate, and thus increase the home’s profit. Molly would have been well aware of the potential for exploitation, despite the 1927 Act. In 1932 the British Journal of Nursing reported that nurses who had failed their preliminary training were: ‘Largely employed in nursing homes, and in what are termed “Co-ops’’ run by persons who have no scruples in supplying them as ‘‘trained nurses” to the ignorant public’.[49] Later in the same year an investigation into nurse shortages by The Lancet continued this theme saying that unqualified or partially qualified people were taking nursing posts in nursing homes.[50] In one oral history recalling nursing in the 1930s, a nurse recounts the story of a fellow student who, having passed her hospital exams but failed her SRN qualifying exam, was working in a nursing home.[51] Molly settled on another establishment, where she did not feel exploited and described all of the nurses as ‘trained’ indicating the calibre of the home, as at the time the law required that only the person in charge was required to be registered. She remained there until her departure for Spain in 1937.
This was a well-appointed converted house owned and run by the Matron. The address was not revealed, but is likely to be close to the Harley Street district in London. It had twenty-two beds and catered mainly for what Molly described as people who: ‘neither knew nor cared anything for the world around them … Many of them were just parasitic wrecks worn out from having “too good a time”’. A minority of patients though were covered by funds held by various doctors.[52]
Her assertion that ‘In the nursing home, nurses really nurse, whilst generally in the hospitals of these days we had to work on factory principles’ can be explored on three counts: firstly, her mutually respectful relationship with medical staff, secondly the diversity of practice and finally the use of her own agency to have an independent, flexible, self-managed career.[53]
One factor that drew Molly in was undoubtedly the calibre and fame of the medical staff. From her early teens she had been accustomed to mix with people who were influential and well-educated, for example the Pankhursts. After her marriage, and through her husband’s connections, she met Lenin and Stalin, and lived in Moscow amongst the international elite of the Communist Party. Thus, she was confident to find herself working with, amongst others, the already mentioned Lord Dawson of Penn and Lord Horder, both of whom were national leaders within the medical profession and physicians to the Royal family.
Molly contrasted her experience as a young nurse in the regimented busy hospital environment at the West London Hospital, where she had trained and worked and where they were permanently understaffed, with the dedicated one-to-one care and close relationships within the Nursing Home: ‘to [the doctors] nurses were indispensable for the treatment of any patient and nothing pleased them more than to find they had a nurse or nurses upon whose judgement they could rely’. She describes herself, and the wider nursing team, being treated as ‘junior medical assistance’, in that the doctor, relying as he did on the nurse for his own success, devoted time to giving her a detailed history and treatment rationale, trusting her to use skill and judgement in its execution; Lord Dawson spent ‘rarely less than 15 minutes’ and Dr Tidy ‘more than 25 minutes’ explaining cases to her.[54]
This dynamic relationship is illustrated when she was nursing a seriously ill child for Dr Tidy:
He had ordered amongst other things, four-hourly treatments of saline. One morning at 2 am I noticed that [the child] had fallen into a quiet sleep … I felt her pulse and watched her closely and had the impression she had slightly improved and it would be a mistake to disturb her. … before going off duty I reported to the sister what I had done, she was rather annoyed. She thought I should have woken her. All day I was restless and slept little. I hurried on duty in the evening and how relieved I was to find our little patient still improving. When Dr Tidy came in, I told him what had happened on the previous night. His reply was very pleasing he said ‘of course you were right not to rouse the child. Look here nurse, you and I have worked together for a long time now and we have confidence in each other. My instructions are only for your guidance’.[55]
The second factor which drew Molly into the nursing home was the quality and diversity of nursing practice she experienced. In addition to gaining management experience through deputising for the matron she nursed a diverse group of patients: a retired widow with gonorrhoea; the wife of a colonial governor needing nasal surgery; a five-year old girl acutely ill and dying of meningitis; a patient described as a ‘noblewoman’ who had attempted suicide; an alcoholic doctor drying out; an elderly woman dying of diabetes; and another refusing treatment despite being very ill with flu. Such a variety of cases required a very wide range of nursing skills, without any of the hierarchical or comradely support that might have been available in a hospital.
Her responsibility for the treatment of a gonorrhoea patient is particularly noteworthy. Legislation in 1916 and 1917 had significantly changed the management of sexually transmitted disease (STDs), making it illegal for a non-qualified person to offer treatment. Molly’s experience of nursing STDs at the West London Hospital equipped her to confidently manage the very exacting four-hourly nursing regimens and strict disinfectant protocols.[56] In the 1930s a conservative MP, Mrs Tate, was campaigning in parliament for more rigid controls of STDs in nursing homes, claiming, with some justification, that infectious cases were not adequately monitored and without very good disinfection there was a grave risk of cross-contamination.[57] That Molly was entrusted to manage her patient’s treatment and safeguard others provides evidence of the confidence that both physician and matron had in her skill.
The care of the acutely ill or dying was different again, as was the ingenuity and interpersonal skills needed to distract and monitor an alcoholic. In addition, the nursing was highly individualised and personal, and on frequent occasions she followed the patient either to a hotel, which could be cheaper for the patient, or back to their own home to continue their care. In such cases she was in sole charge of the nursing care with no supervision.
Clearly all of these factors were important to Molly. Despite her antipathy to many of the patients for their lack of awareness and interest in the world around them, the nursing work was, at times at least, genuinely interesting, rewarding and engaging; it gave her a breadth of practice she would have been unlikely to experience in a hospital setting. However, the third factor, her independence and autonomy, was perhaps the most important one.
From the outset Molly took command of her situation. Her return to work may have been precipitated by her husband Jack’s dramatic resignation from the CPGB, but as has been discuss earlier, she chose the direction to take. She used her personal judgement regarding the salary she would accept, and remained independent so that she could follow a patient’s care through to their home, or to a hotel if she thought it was needed. Molly stated that as a nurse in a cooperative association she would likely get £3/10 shillings per week less her lodgings; but as an independent nurse living at home (once she had established herself), she could negotiate four guineas per week.
Molly maintained direct, collegiate contact with the matron who entrusted her enough to allow Molly to deputise for her. She treated the doctors as equals, not superiors, and on one occasion, advocated independently for a patient who she believed was being exploited. Molly knew that the patient’s treatment was complete but the doctor wanted that kept quiet, stating: ‘“I don’t want this patient to slip through my hands. You see to it that she comes to me three times per week” … this was the first and only time in my nursing career that a doctor ever spoke to me in this manner’.[58] In defiance of this subterfuge Molly advocated for her patient by advising that she attend a clinic at the West London Hospital, to be reassured of her cure.
Having supported her husband’s career for the first part of her marriage, Molly used nursing to make a significant impact on family finances, changed her role in the family and rediscovered her own career. How long Molly might have remained as a nursing home nurse is hard to judge. By 1937 Jack had recovered his reputation as a writer, journalist and politician, so her employment was no longer an imperative. However, it was the call for nurses to volunteer for Medical Aid to Spain that swept Molly from the well-to-do streets of London onto the Spanish battlefields.
Such a detailed record of nursing home nursing in the inter-war period is rare, although two oral histories have been identified that also, albeit briefly, describe nursing home experience contemporary to that of Molly’s. First is an eighteen-year-old ‘lady’ (by her own description) who completed a three-year contract as a probationary nurse in a ‘tiptop’ private nursing home in the 1920s. She describes it as invested in collectively by all the local doctors, twinned with a nursing home in London and keen to offer probationers a structured educational experience which might lead to a full nursing qualification. She had: ‘a very good training …. always surgical work … we had to get all the trays ready … I learned dressings, sterilisation, everything else’.[59] The second oral history describes a the experience of a Sate Registered Nurse who, in the mid-1930s, had travelled from Scotland to London, and found work in a private, expensive, surgical establishment in a fashionable area of London. Like Molly, at times this nurse found herself following patients’ care beyond the home, but also stated that they were treated much as hospital nurses.[60] Both testimonies, whilst offering only a fleeting glimpse, echo Molly’s experience of nursing home nursing. By contrast, Baroness de T’Serclaes in her memoir, dismisses the year she spent working in a nursing home between the wars in a couple of sentences, as one of drudgery and frustration because her nursing experience was neither recognised nor utilised.[61]
Conclusion
The need for safe, affordable nursing care for the many sick or vulnerable people in Britain unable to continue to live in their own homes is as vital now as it was one hundred years ago. Understanding the issues that led to parliamentary investigation and legislation highlights the intractable problems of funding and safeguarding a for-profit system when many of the patients are frail and helpless.
Molly’s detailed account of nursing home nursing brings to life, then as now, this often poorly respected and under-researched sector. She does not deny the issues that continued to affect nursing homes: she experiences first-hand how exploitation of nurses and patients could take place, even in a particularly high class, high fee establishment. However, her memoir reveals a nursing world full of promise, reward and respect. One hundred years after Mortimer’s private nurses advertised their service in Edinburgh, despite the huge changes in nursing practice, location and education, Molly embodies the same confident, successful, professional profile.
References
[1] Ralph Darlington (ed.), Molly Murphy: Suffragette and Socialist (Salford: University of Salford,1998) 126/27.
[2] In the period of this research ‘home hospital’ and ‘nursing home’ are sometimes used interchangeably. In current British legislation ‘care home’ denotes a place offering nursing and ‘residential home’ a place which does not.
[3] At the height of the pandemic in Britain, from 2 March to 12 June 2020 around 30% of the 66,000 deaths of English care home residents could be attributed to the coronavirus. The death rate was significantly higher than usual across the country as a whole but care home residents were over-represented. ‘Deaths involving COVID-19 in the care sector, England and Wales Office of National Statistics’ (2020). [online]. Available at:https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/deathsinvolvingcovid19inthecaresectorenglandandwales/deathsoccurringupto12june2020andregisteredupto20june2020provisional [Accessed 30 July 2022].
[4] Robert Dingwall, Anne Marie Rafferty and Charles Webster (eds), An Introduction to the Social History of Nursing (London: Routledge,1988).
[5] Jane Austen, Persuasion (Middlesex: Penguin Harmondsworth, 1965).
[6] Alannah Tompkins ‘“I helpt to nurse”: unpaid care work by Georgian spinsters 1780-1820’, UKAHN Bulletin 10 (2022).
[7] Barbara Mortimer, ‘Independent Women: Domiciliary nurses in mid-nineteenth-century Edinburgh’, in Nursing History and the Politics of Welfare, ed. by Anne Marie Raftery, Jane Robinson and Ruth Elkan (London: Routledge, 1997) 133-149.
[8] Ibid.
[9] Ibid.
[10] Sarah Tooley, The History of Nursing in the British Empire (London: S H Bousfield & Co Ltd, 1906) [online]. Available at: https://iiif.wellcomecollection.org/pdf/b21686695 [Accessed 3 September 2022].
[11] Sue Hawkins, Nursing and Women’s Labour in the Nineteenth Century: The Quest for Independence (Abingdon: Routledge, 2010).
[12] Stuart Wildman, ‘Local nursing associations in an age of nursing reform, 1860-1900’ (Unpublished PhD thesis, University of Birmingham, 2012). Available at: http://etheses.bham.ac.uk//id/eprint/3883/ [Accessed 10 August 2022].
[13] Jisc Archives hub, ‘Bertha Marion Broadwood, Correspondence and papers’ [online]. Available at: https://archiveshub.jisc.ac.uk/search/archives/bcf8675a-b869-3810-ab3d-b04064bd048b. [Accessed 10 August 2022].
[14] Wildman, ‘Local Nursing Associations’; Tooley, The History of Nursing.
[15] Tooley, The History of Nursing. For a detailed history of nursing at The London see: Sarah Rogers, ‘A Maker of Matrons’? A study of Eva Lückes’s influence on a generation of nurse leaders:1880–1919’ (Unpublished PhD thesis, University of Huddersfield, 2022).
[16] Francis Watson, Dawson of Penn (London: Chatto and Windus,1950); Catherine Black, King’s Nurse – Beggar’s Nurse (London: Hurst & Blackett,1939).
[17] Hawkins, Nursing and Women’s Labour,166.
[18] Annie Smithson (ed.), In times of Peril: Leaves from the diary of Nurse Linda Kearns from Easter week 1916 to Mountjoy 1921 (Dublin: The Talbot Press, 1921).
[19] Brian Abel-Smith and Robert Pinker, The Hospitals, 1800-1948: A Study in Social Administration in England and Wales (California: Harvard University Press,1964); Sheila Peace, ‘The Development of Residential and Nursing Home Care in the United Kingdom’, in End of Life in Care Homes: a palliative care approach, ed. by Jean Samson Katz and Sheila Peace (Oxford: Oxford Academic, 2003),15-21.
[20] ‘Report from the Select Committee on Nursing homes (Registration), together with the Proceedings of the Committee, Minutes of Evidence, and Appendix’, 6 July 1926 [online]. Available at: https://parlipapers.proquest.com/parlipapers/docview/t70.d75.1926-027900/usgLogRstClick!!?accountid=11526 [Accessed 9 August 2022].
[21] Tooley, The History of Nursing.
[22] Ibid.; Historical Directories of England & Wales, Post Office London Directory, 1841; Post Office London Directory,1852; Post Office London Directory,1882,1666 [online]. Available at: https://specialcollections.le.ac.uk/digital/collection/p16445coll4 [Accessed 9 August 2022].
[23] ‘Home Hospitals’, Nursing Record, 4 May (1895), 293-4 [online]. Available at: https://rcnarchive.rcn.org.uk/volumes/14/Volume%2014%20Page%20293 [Accessed 11 August 2022]; Tooley, The History of Nursing, 265.
[24] ‘Horatio Bottomley Biography’ [online]. Available at: https://spartacus-educational.com/FWWbottomley.htm [accessed 10 August 2022].
[25] ‘Nursing Homes Or – ?’ John Bull, a series of weekly articles running from 14 May to 16 July (1910) [online]. Available at: https://www.britishnewspaperarchive.co.uk/ [Accessed 11 August 2022].
[26] Stephen Halliday, The Great Filth, Disease, Death & the Victorian City (Gloucester: The History Press, 2010); Bernard Harris, The Origins of the British Welfare State: society, state, and social welfare in England and Wales, 1800-1945 (Hampshire: Palgrave Macmillan, 2004).
[27] ‘The 1848 Public Health Act’ [online]. Available at: https://websearch.parliament.uk/?q=1848%20oubolic%20health%20Act [Accessed 10 August 2022]; ‘The1866 Sanitary Act’ [online]. Available at: https://websearch.parliament.uk/?q=1866+sanitary+act [Accessed 10 August 2022]; Halliday, The Great Filth.
[28] ‘The Mental Deficiency Act 1913’ [online]. Available at: https://wellcomecollection.org/works/h7ykpfbw/items?canvas=4 [Accessed 10 August 2022].
[29] ‘The Midwives Act 1912’ [online]. Available at: https://navigator.health.org.uk/theme/midwives-act-1902 [Accessed 10 August 2022].
[30] ‘Report from the Select Committee on Registration of Nurses Together with the Proceedings of the Committee. Minutes of Evidence and Appendix. House of Commons’ 25 July 1905 [online]. Available at: https://parlipapers.proquest.com/parlipapers/docview/t70.d75.1905-004790/usgLogRstClick!!?accountid=11526 [Accessed 10 August 2022].
[31] Eve Bendall and Elizabeth Raybould, A History of The General Nursing Council for England and Wales 1919-1969 (London: H. K. Lewis & Co. Ltd., 1969); ‘ The Nurses Registration Act’ [online]. Available at: https://navigator.health.org.uk/theme/nurses-registration-act [Accessed 11 August 2022].
[32] ‘Report from Select Committee, 1926: Order of reference’, ii.
[33] Ibid., Report, para 10.
[34] Ibid., Proceedings paras 3060-3151.
[35] Ibid., Proceedings, para 750.
[36] Ibid., Proceedings, paras 2361-2579.
[37] Ibid., Report, para 33.
[38] Ibid., Proceedings, paras 1872-1910.
[39] Tooley, The History of Nursing.
[40] ‘Report from Select Committee’, 1926: Proceedings, para 572.
[41] Ibid., Report, para 38.
[42] ‘House of Lords Debate, Nursing Homes Registration Bill’, Hansard 69, col 1218/9 (20 December 1927) [online]. Available at: https://hansard.parliament.uk/Lords/1927-12-20/debates/39d7a6c2-5270-42a7-937c-0d2352a0d2de/NursingHomesRegistrationBill?highlight=dawson%20penn#contribution-2cc9f88c-638d-429d-a366-c67f948589c5 [Accessed 10 August 2022].
[43] For a short biography of Molly Murphy see: Janet Hargreaves, ‘Molly Murphy (née Morris) Nurse, Socialist and Suffragette’, UKAHN Bulletin 7 (2019).
[44] Peoples History Museum (PHM), CP/IND/MURP, Original transcript of memoir ‘Nurse Molly’; Ralph Darlington (ed.), Molly Murphy: Suffragette and Socialist (Salford: University of Salford,1998).
[45] Ralph Darlington, The Political Trajectory of J T Murphy (Liverpool; Liverpool University Press, 1998).
[46] Bedales (https://www.bedales.org.uk/about-us/history ) was a progressive boarding school favoured by people wanting to avoid the authoritarian ethos of mainstream education.
[47] Darlington, Molly Murphy, 124.
[48] Jack Murphy, New Horizons (London: John Lane The Bodley Head, 1941), 307.
[49] ‘Nursing Echoes’, British Journal of Nursing, 80 (February 1932), 31. Available at: https://rcnarchive.rcn.org.uk/volumes/80/Volume%2080%20Page%2031 [Accessed on 11 August 2022].
[50] Report of The Lancet Commission on Nursing, Volume 80, March 1932 p70 -73; [online]. Available at:,https://rcnarchive.rcn.org.uk/volumes/80/Volume%2080%20Page%2070 [Accessed on 11 August 2022].
[51] T177, Oral History, Royal College of Nursing Archive.
[52] Darlington, Molly Murphy, 127.
[53] Ibid., 126/27.
[54] Ibid., 126.
[55] PHM, Nurse Molly, 117-8.
[56] For more background, see British Association for Sexual Health and HIV website [online]. Available at: https://www.bashh.org/news/blogging-4-bashh/sexual-health-what-happened-100-years-ago-was-remarkable/. [Accessed 12 August 2022]; Millicent Ashdown, A Complete System of Nursing (London: Dent & Sons, 1934).
[57] ‘House of Commons Debate’, Hansard, 314, cc 2318-2319 (16 July 1936); and Vol 324, cc 1661 (8 June 1937) [online]. Available at: https://hansard.parliament.uk/commons [Accessed 12 August 2022].
[58] Darlington, Molly Murphy, 127.
[59] T/12B Oral History, Royal College of Nursing Archives.
[60] T/128 Oral History, Royal College of Nursing Archives.
[61] Baroness de T’Serclaes, Flanders and other Fields (London: George G Harrap & Co. 1964). The Baroness was a renowned British nurse and ambulance driver during World War One.
