Tag: Health

Developments in District Nurse Training, 1890-1919

For today’s post, I will briefly analyse the developments in nurse training from the late nineteenth century to the introduction of the 1919 Nurses Registration (Ireland) Act.

Under the 1851 Medical Charities Act dispensary midwives were appointed to work in a local dispensary district. Ciara Breathnach ‘Handywomen and Birthing in Rural Ireland, 1851-1955’ (41) argues that although, the dispensary midwife was employed in the local dispensary, ‘distances from dispensaries and union hospitals coupled with a reticence to engage with medical care under the poor law served as deterrents for pregnant women’. Many women continued to avail of the handywomen’s service rather than the district voluntary nurses due to a difficulty in the community to raise funds to support a nursing association (Ibid, 40). ‘Handywomen’ were untrained midwives and facilitated the spread of disease amongst new mothers. However, most women did not give birth in hospitals and there was no ante-natal provision available during late nineteenth century in Ireland. Joe Robins’ Nursing and Midwifery in Ireland in the twentieth century: fifty years of an Bord Altranais (the Nursing Board) 1950-2000 (14) highlights that ‘the family home was accepted as the proper place for birth’. Many women died from puerperal sepsis and other conditions related to birth.  

Most nurses were untrained during the nineteenth century, with a bad reputation for drunkenness and their lack of education (Gerard Fealy, A History of Apprenticeship Nursing in Ireland, 18). However, Florence Nightingale influenced the new value of morality becoming a requirement for nursing during the second half of the nineteenth century (Ibid, 11). Apprenticeship nurse training then developed during the 1890s and nurse training schools were attached to ‘voluntary hospitals and in the large hospitals operated by religious orders’ (Robins, Nursing and Midwifery, 11). Nurse training was denominational and there were separate training schools for Protestant and Catholic nurses. Maria Luddy’s ‘‘Angels of Mercy’: Nuns as Workhouse Nurses, 1861-1998’ (106) states that religious orders, drawing recruits from educated middle classes, played a significant role in the establishment of nurse training and thereby helped to raise nursing standards including the Sisters of Mercy. To train as a nurse, women were required to have a good moral character, ‘a positive reference and an ability to pay a general fee to the training school’ (Ann-Marie Ryan, ‘General Nursing’, 79).Various nursing trainings schools were set up including The Dublin Metropolitan Technical School for Nursing during the 1890s (Robins, Nursing and Midwifery, 14). 

By 1900 attempts were made to provide official training for district nurses and various organisations such as Lady Dudley’s Nursing scheme (1903) and Queen Victoria’s Jubilee Institute (1897) organised voluntary nursing services throughout rural and poor parts of Ireland. The nurses treated a range of illnesses including tuberculosis and they often arrived to treat patients following a ‘referrals from general practitioners, the Jubilee Committee and pharmacists’ (Armstrong, ‘Public Health Nursing, 127). According to Armstrong (Public Health Nursing’, 127), the district nurses were trusted by the community as they had the power to convince patients to receive vaccinations. However, they worked long hours as they held a dual role of midwife in many districts (Ibid). The voluntary nursing services were limited in Ireland as Breathnach ‘Lady Dudley’s District Nursing Scheme and the Congested Districts Board, 1903-1923’ (151) states that there were only a small number of Lady Dudley nurses: only 21 for 24 congested districts. It was a free service and the nurses travelled from areas on bicycle (Robins, Nursing and Midwifery, 12).

In 1919, the Nurses Registration (Ireland) Act was introduced, establishing the General Nursing Council, and a register for separate nursing divisions including general nurses and mental nurses and the Council would supervise nurse training, inspections and examinations. Nurses had to be enrolled in a training hospital in order to join the register. Moreover, a Central Midwives Board was founded and midwifery training would take place in maternity hospital for six months (Robins, Nursing and Midwifery, 17). Armstrong ‘Public Health Nursing’ (127) maintains that ‘the district nurses was also the appointed midwife for the area’ and they worked all day as they may be called to treat an injury or an illness. After the Irish Free State was established in 1922, the new Department of Local Government and Public Health funded Maternity and Child Welfare schemes and half the costs of local authority and voluntary nursing association nurses (Annual Report of the Department of Local Government and Public Health, -1925, 34). However, nurses were given insufficient wages by by the government and local rates (Commission on the Relief of the Sick and Destitute Poor Including the Insane Poor appointed on the 19th March 1925, 65-66). However, by 1927, general nurses in many counties only had midwifery skills (Ibid, 66).

Voluntary scheme provided an essential service to the sick poor by travelling to patients in rural parts of Ireland. By the twentieth century, most nurses were moral and middle class women trained in a voluntary hospital or training school based in Dublin. District nurses employed by local authorities or voluntary nursing associations carried out a wide range of duties such as the maternity and child welfare schemes and preventive health services. However, district nurses continued to be over-worked and underpaid by the DLGPH and local rates in the Free State.

Bibliography

Primary sources

Annual Report of the Department of Local Government and Public Health, 1925-28, (Stationary Office, Dublin, 1928).

Commission on the Relief of the Sick and Destitute Poor Including the Insane Poor appointed on the 19th March 1925 (Stationary Office, 1927).

Nurses Registration (Ireland). A bill to provide for the registration of nurses in Ireland.

Secondary Sources

Armstrong, Sheila, ‘Public Health Nursing’ in J. Robins (ed.) Nursing and Midwifery in Ireland in the twentieth century: fifty years of an Bord Altranais (the Nursing Board) 1950-2000 (An Bord Altranais, Dublin, 2000), pp.125-139.

Breathnach, Ciara, ‘Lady Dudley’s District Nursing Scheme and the Congested Districts Board, 1903-1923’ in in M. H. Preston and M. O’ hOgartaigh (eds.) Gender and Medicine in Ireland, 1700-1950 (Syracuse University Press, New York, 2012), pp. 138-153.

Breathnach, Ciara, ‘Handywomen and Birthing in Rural Ireland, 1851-1955’, Gender and History, Vol. 28, No. 1 (April 2016), pp.34-56.

Fealy, Gerard M, A History of Apprenticeship Nurse Training in Ireland, Routledge, London, 2006.

Luddy, Maria, ‘‘Angels of Mercy’: Nuns as Workhouse Nurses, 1861-1998’ in G. Jones and E. Malcolm (eds.) Medicine, Disease and the State in Ireland, 1650-1940, (Cork University Press, Cork, 1999), pp.102-117.

Robins, Joe, Nursing and Midwifery in Ireland in the twentieth century: fifty years of an Bord Altranais (the Nursing Board) 1950-2000, An Bord Altranais, Dublin, 2000.

Ryan, Anne-Marie, ‘General Nursing’ in in J. Robins (ed.) Nursing and Midwifery in Ireland in the twentieth century: fifty years of an Bord Altranais (the Nursing Board) 1950-2000 (An Bord Altranais, Dublin, 2000), pp.77-99.

Health Visitation and Maternity and Child Welfare Centres: the Expansion of Maternal and Infant Provision, 1915-1930

 In 1900, maternal mortality rates were high in Ireland due to numerous factors. The only provision available to mothers was through the dispensary midwife from the local dispensary and voluntary nursing associations such as Lady Dudley’s nurses. Moreover, most women did not give birth in hospital and relied on a handywoman, an untrained midwife, to assist with childbirth. This practise often resulted in the spread of infection to the new mother. According to the 37th Annual Report of the Registrar General, 6.4 per 1,000 women died in birth from puerperal fever or other diseases linked to parturition in 1900.

At the start of the twentieth century infant mortality rates were extremely high due to the spread of infectious diseases such as diphtheria, pneumonia, gastro-enteritis and tuberculosis. In 1900, the Registrar General’s report stated that 38 per 1,000 children under five years of age died.  According to Joe Robin’s Nursing and Midwifery in Ireland in the twentieth century: fifty years of an Bord Altranais (the Nursing Board) 1950-2000, the high infant mortality rate was influenced by various socio-economic factors including a lack of nutrition and an unclean living environment. Poor mothers were not educated on sanitation, nutrition, breastfeeding and infant illnesses.  However, independent initiatives were established by middle class women such as the Women’s National Health Association in 1907 to reduce the high infant and maternal mortality rates in Ireland and to educate mothers on breastfeeding and cleanliness.

In 1907, the Notification of Births Act was passed, however, it did not make the notification of births compulsory. Under the 1915 Notification of Births (Extension) Act, health visitation was introduced for new and nursing mothers and children under the age of five. The Local Government Board was made responsible for the establishment of Maternity and child welfare centres and for the distribution of  food to mothers and young children. However, the act only applied to urban areas. 

In 1918, the Maternity and Child Welfare Act was passed, requiring local authorities to ensure provision for nursing and expectant mothers and children under five including health visitation, maternity and child welfare centres and free food and milk to poor mothers and young children. Nurses from voluntary nursing associations were mainly employed by local health authorities to undertake the health visitation service. It sought to educate mothers on nutrition and breastfeeding, thus helping to eradicate the ignorance of mothers about childbirth and babies. Significantly, in 1918, the Central Midwives Board was set up and a register of trained midwives was introduced to ensure that the practise of handywoman was discontinued. A register for general nurses was also introduced under the 1919 Nurses Registration Act.

During the 1920s, health services such as hospitals were co-ordinated. In 1923, a County Medical Officer was appointed to manage county health schemes including maternal and infant health services. Health visitors were appointed to work in the maternity and child welfare centres in county boroughs with high infant mortality rates including Dublin and Cork. They educated the expectant or nursing mother on childbirth and dangers of handywomen. The DLGPH’s Report 1922-1925 stated that ‘the ultimately the remedy lies in the gradual enlightenment of expectant mothers with regard to risks involved’. The Irish Nurse’s Union Gazette advised that the public health nurse to teach mothers through physical instruction rather than an explanation, for example, ‘by boiling the water we are going to use we can demonstrate the principle of sterilisation’. However, health visitation continued to be the only provision available to women in rural areas.

The high infant mortality rates encouraged the growth of the schemes in other counties and county boroughs. According to Report of the Commission on the Relief of the Sick and Destitute Poor Including the Insane Poor appointed 19th March 1925, by 1925, there were 93 Maternity and Child Welfare schemes in operation throughout the country. The maternity and child welfare centres were funded by the Irish government. They funded half the costs of the voluntary nurses working under the Maternity and Child welfare schemes while the remainder was paid by local rates. It was mainly voluntary nurses that operated the maternity and child welfare schemes. Ruth Barrington’s Health, Medicine &  Politics in Ireland, 1900-1970 maintained that in 1927, the first child welfare centre was set up in Lord Edward Street, Dublin, providing health education to mothers and public health nurses could refer patients for specialist treatment. Specialist treatment included treatment for medical conditions including rickets. 

By 1930, the notification of births began in urban districts in countiessuch as Donegal. The voluntary nurses managed more maternity and child welfarecentres than district nurses employed by local authorities. According to the DLGPH’s Report 1930-31, health visits were carried out to 18,379 mothers and 33,930 children and 37,914 mothers in their homes. The Maternity and Child Welfare Schemes also provided free milk to poor mothers and infants. The DLGPH’s report 1930-1931stated that a Maternity and Child Welfare Centre opened at Tukey Street, Cork in 1931. Lindsey Earner-Byrne’s Mother and Child: Maternity and Child Welfare in Dublin, 1922-60 argues that Maternity and Child Welfare Schemes in urban areas including Dublin, Limerick and Cork were co-ordinated with the maternity hospitals, facilitating the development of ante-natal services.

Significantly, the 1915 Notification of Births (Extension) Act was the first attempt by the British government to establish provision for mothers and infants in Ireland. Importantly, the Nurses Registration Act 1919 and the Midwives (Ireland) Act 1918 marked the beginning of the decline of untrained handywomen and nurses. Maternal and infant provision was reinforced by the County Medical Officer whom oversaw their gradual introduction into county boroughs. By 1930,numerous maternity and child welfare centres were established and the number of health visits undertaken by nurses increased. They offered an ante-natal service to expectant mothers and the provision of food and milk for poor mothers and children under 5 helped to reduce medical conditions linked to malnourishment.

Further reading:

Annual Report of the Department of Local Government and Public Health, 1925-28,(Stationary Office, Dublin, 1928).

Annual Report of the Department of Local Government and Public Health, 1930-31,(Stationary Office, Dublin, 1931).

Barrington, Ruth, Health, Medicine & Politics in Ireland, 1900-1970, Institute of Public Administration, Dublin, 1987.

Commission on the Relief of the Sick and Destitute Poor Including the Insane Poor appointed on the 19th March 1925 (Stationary Office, 1927).

Earner-Byrne, Lindsey, Mother and Child: Maternity and Child Welfare in Dublin, 1922-60, Manchester University Press, Manchester, 2007.

Irish Nurses Union Gazette, No.29 (January, 1930).

Robins, Joe, Nursing and Midwifery in Ireland in the twentieth century: fifty years of an Bord Altranais (the Nursing Board) 1950-2000, An Bord Altranais, Dublin, 2000.

Thirty-seventh detailed Annual Report of the Register-General (Ireland) containing a General Abstractof the Numbers of Marriages, Births and Deaths Registered in Ireland During the Year 1900.