Years after the incident occurred, Lady Victoria Lambton still remembered a medical emergency that took place near her Pembrokeshire estate on the rocky southwestern coast of Wales. The victim was an agricultural worker – a young man in the prime of life. While working in the fields, he fell into a reaping machine and was ‘fearfully cut’. The man lay in the field for hours before his fellow workers were able to obtain a gig from a nearby farmhouse to transport him to the closest infirmary. No one was surprised when he died shortly after an agonising nine-mile ride to assistance. ‘There was no nurse in the district, or a great deal of this suffering might have been spared’, Lambton said.Footnote 1 It was emergencies like this one that helped persuade her that rural nurses should be as thoroughly trained as possible, prepared to contend with medical misadventures far from the nearest hospital or physician. In the 1880s, she became one of a growing number of elite women across the United Kingdom to respond to the healthcare needs of their tenants and neighbours by establishing a local district nursing association.Footnote 2
Established in the slums of Liverpool in 1859, the philanthropic district nursing movement aimed to universalise access to the emerging vanguard of professional nursing. Thoroughly trained and respectable, district nurses brought the latest knowledge on sanitation and nursing care into impoverished homes as they travelled from one patient to another. Previously, only those able to afford a private nurse had had access in the comfort of their own homes to nurses trained to this degree, but district nursing supporters pursued the admirable dream of making the best possible nurses available to the most necessitous patients. When it came to extending the movement beyond the United Kingdom’s main cities, however, not all agreed that district nurses were well-suited for rural contexts. Victoria Lambton was dismayed when she encountered a fellow lady landowner who flatly refused to employ a district nurse, opting instead to give only rudimentary training to some local village women. Simply-trained country women would not only be less expensive than district nurses but also better equipped for rural nursing, the lady landowner argued, observing that ‘a trained nurse is quite unsuited to this district, which is a very poor and agricultural one’. This viewpoint galled and baffled Lambton: ‘The ladies who oppose having a trained nurse for the poor would probably send for one to attend themselves or any of their family in illness’, she quipped, ‘… I cannot understand it’.Footnote 3
This paper endeavours to understand what Lambton could not, examining the rise and fall of a controversial approach to rural healthcare known as cottage nursing. Established by Bertha Broadwood in 1883, the cottage nursing movement contravened many of the lofty ideals of an age of escalating healthcare expectations, specialising instead in prosaic realities and lowest acceptable minimums. While leading nursing reformers and philanthropists in the late nineteenth to mid-twentieth centuries tended to push for longer training, recruitment from higher social classes, and stricter parameters for the kind of labour nursing entailed, cottage nursing supporters bedevilled such efforts, championing nurses with simple training, low social status, and a willingness to help their patients with even the most menial domestic labour. They did so for both logistical and ideological reasons. Cottage nursing supporters pointed to the seeming impossibility of extending the latest urban healthcare expectations to rural areas of the United Kingdom, where the best-trained and highest-status practitioners could seldom be attracted or afforded. Often, they went further, suggesting that such nurses were undesirable even if obtainable because of distinctive rural preferences and needs. They argued that rural patients preferred unpretentious and briefly-trained nurses who more closely approximated the care of the handywomen and neighbours who had long assisted them without any institutional preparation.
For their views, cottage nursing supporters were often accused of an unbecoming willingness to provide the poor with substandard care. Their critics cited patient safety, enumerating the dangers of sending ‘half-trained’ nurses to work amongst people in need of serious medical assistance. Broadwood, however, was quick to observe that the ‘little knowledge’ given to her briefly-trained cottage nurses was ‘a dangerous thing’ not so much for patients, who would often otherwise have access to no trained nursing whatsoever, but professionals, who viewed cottage nurses as undermining efforts to transform nursing into a desirable profession that demanded a certain threshold of preparation and respectability.Footnote 4 Broadwood staunchly maintained that although she was ‘despised by all the nursing world’ for her threateningly low standards, she was merely ‘endeavouring to bring to cottagers what cottagers wanted’, and prioritising life-saving progress for rural patients over the pursuit of perfection.Footnote 5
This article uses the writings of cottage nursing supporters to interrogate the moral high ground long claimed by their chief opponents, those who championed the noble ideal of providing the same high standard of care to all. This ideal remains an enduringly appealing one, and to understand how it could be questioned by Broadwood and others requires a significant shift in perspective. In what follows, I examine well-trodden episodes from the history of nursing, midwifery, and healthcare in the United Kingdom from the doubly peripheral perspective of cottage nursing supporters. I suggest that, from their vantage on the professional and geographic margins of the United Kingdom, they were well-positioned to question the methods and motivations of a predominantly urban professional intelligentsia that claimed to have the best interests of rural patients at heart. Cottage nursing supporters campaigned for compromise, anticipating the strain that distance and poverty would put on the best intentions. They warned that the costs of greater professional rigidity and exclusivity would be ultimately borne by the rural poor, who could scarcely afford such idealism. I argue that at key moments of debate from the 1880s to the interwar period Bertha Broadwood and her controversial nurses exposed an uncomfortable truth: The noble healthcare ideals and excellent standards of their critics could simultaneously be pursued on behalf of rural patients and at their expense. More broadly, I use the story of the rise and fall of the cottage nursing movement to demonstrate how rural perspectives can be used to disentangle frequently conflated narratives of professionalisation and progress in the history of medicine and healthcare.
Despite decades of poststructuralist and postcolonial critique, intuitive narratives associating professionalisation, modernity, and progress have proven difficult for historians of medicine and its allied professions to escape. In a 2021 essay, Keir Waddington argues for the need for continued ‘conscious interrogation’ of concepts like ‘progress’ and ‘backwardness’ in the social history of medicine. As one possible route ‘out of the problem of modernity’, Waddington has suggested ‘shifting the focus’ from the urban lab or hospital ‘to areas commonly framed as backwards’, including especially rural places.Footnote 6 In this way, he builds upon scholarly calls to centre various ‘peripheries’, including both rural and colonial contexts. Such places often failed to conform to dominant narratives of change, pointing instead to the importance of constraint, syncretism, and compromise in the history of healthcare. This article contributes to a growing number of studies examining the challenges of providing healthcare in sparsely populated and poorly resourced rural zones where improvisation and compromised standards were often deemed necessary.Footnote 7 Debates over the need to compromise and establish ‘some kind of two-tier system’ with more and less prepared nurses have been predominantly examined in the context of the urban hospital, where dependence on briefly-trained probationers, orderlies, and, eventually, assistant nurses has often proved unavoidable due to shortages of qualified personnel.Footnote 8 A similar but less thoroughly examined debate over the need for different grades of nurses also runs through the history of rural nursing. Indeed, this debate has extended into the modern era: The question of how to secure well-trained nurses for rural regions that struggle to attract or afford them remains an unresolved one in many parts of the world today.Footnote 9
As a second recommendation for counteracting an ‘implicit framework of modernity’ in the social history of medicine, Waddington recommends a shift toward comparatively neglected ‘everyday’ or ‘mundane’ subjects.Footnote 10 His advice follows in the tradition of those who have long called for more works on low-status, non-conforming, and popular healers to counteract a scholarly emphasis on professional elites. Within the history of nursing, a tendency to focus on those working in institutional or urban settings has worked to sideline and obscure the quotidian and domestic work of cottage nurses. Interest in the profession’s gendered struggle for respect for many years led to a propensity to highlight individuals at the forefront of this battle, who were often well-educated, comparitively elite, and located in urban centres. In the decades since, historians have worked to expand who is highlighted in the history of nursing, and this article contributes to ongoing efforts to examine the work of lower-status nurses.Footnote 11 There are no dedicated histories of Bertha Broadwood or her nurses, and where they are occasionally referenced in works on better-trained nurses, they have often been cast as challengers to the progress championed by their critics.Footnote 12 This article positions cottage nursing supporters as critics themselves, dissenting reformers who attempted to interject rural perspectives into national debates over the nature of and need for professional nursing care.
Until legislation brought greater legal clarity to the meaning of the term ‘nurse’ in 1919, the terminology used to describe different kinds of nurses was used with considerable imprecision. Bertha Broadwood, however, was strikingly clear-headed about what cottage nursing was – and what it was not. In this article, I adopt her definitions, using the term ‘cottage nurse’ to refer to nurses who conformed to Broadwood’s distinctive vision for in-home care and had three distinguishing qualities: (1) They were trained in homes, not hospitals. (2) They nursed one patient at a time, staying with them for days or weeks. (3) They both provided nursing care and assisted with domestic labour. I use the term ‘district nurse’ to refer to nurses who had hospital training and specialised district training (sometimes also followed by midwifery certification) that prepared them to travel to the homes of patients in their assigned ‘district’, typically visiting several patients in one day. In order to understand what made cottage nursing so divisive, one must begin with district nursing, which served as the ideological foil for Bertha Broadwood’s against-the-grain approach.
‘…ladies of good position’: The district nursing movement
From its earliest days, the district nursing movement was associated with the drive to transform nursing into a desirable and respectable profession. As the argument that nurses needed formal training gained ground and new institutions were established in the 1860s and 70s to provide it, pioneering district nursing associations employed some of the first graduates of these programmes. Philanthropist William Rathbone has often been credited with initiating the district nursing movement in 1859, when he modelled the ideal of providing the same quality of care to rich and poor alike by sending the same woman who cared for his wife in her final illness to nurse one of Liverpool’s poorest neighbourhoods.Footnote 13 District nursing quickly spread to many of the United Kingdom’s largest cities, and in 1874 work began on London’s Metropolitan and National Nursing Association (MNNA), which soon emerged as a standard-setting district nursing association. While many early training hospitals accepted both regular (often working-class) probationers and paying ‘lady’ pupils, the MNNA recruited lady nurses who had both hospital and specialised district training to prepare them to care for London’s poor.Footnote 14 Women of superior class and training, the MNNA’s organisers argued, were uniquely equipped for the special responsibilities of district nursing, which involved working independently in private homes that lacked the comforts or supervisory support of a hospital.Footnote 15
The MNNA’s high standards reflected the priorities of a growing number of professional elites and reformers, mostly concentrated in major urban centres, working to better define and police the boundaries of trained healthcare provision. From the 1880s onward, new reform movements pushed for a formal registration process for those who wished to practice as either midwives, nurses, or both. Proponents of midwifery registration hoped to create a trustworthy register of certified midwives who had passed a certification examination.Footnote 16 Simultaneously, a nursing registration movement led by the outspoken Ethel Bedford Fenwick campaigned for a minimum of three years’ hospital training and enrolment on a national register for anyone who wished to call themself ‘nurse’.Footnote 17 Disagreements over training duration and how to best evaluate competency were rife, but many reformers and professionals increasingly found a common enemy in women who lacked any kind of institutional training or certification. These women were often held up as an example of the inadequacies of unreformed care and the need to replace ‘untrained’ with ‘trained’ practitioners.
By the final decades of the 19th century, ‘untrained’ nurses and midwives were strongly associated with poor communities, especially in rural areas of the United Kingdom. From the ‘howdies’ of Scotland to the ‘handywomen’ of English villages, the healers of the rural poor were known by many names. Footnote 18 Often prepared for her work by some combination of inherited knowledge, practical experience, or informal apprenticeship, the handywoman was typically qualified to care by the trust of her neighbours, not an institution. Footnote 19 This sometimes earned her the title of ‘untrained’ from outsiders, although many handywomen had considerable knowledge and extensive experience. Governed by no professional parameters for their work, handywomen might lay out the dead, prepare or prescribe medicines, provide sick nursing, doctor wounds, or deliver babies. Working for lower fees than a doctor, many handywomen were also willing to accept payment in kind, making them a critical and affordable source of support in times of illness. Some worked for no fee at all. Personally familiar with the difficulties of managing a country cottage while ill, handywomen sometimes stayed with recovering patients (especially parturient mothers) for days or weeks, assisting with cooking, cleaning, and childcare. Reformers who from the 1880s looked to replace the handywoman with district nurses thus faced a daunting task. While, like the handywomen, district nurses provided in-home care, most district nursing associations dissuaded them from laying out the dead, undertaking heavier household tasks, or spending the night in the homes of their patients. Such restrictions, designed to delineate between trained and untrained care, elevated the status of district nurses but also had the unintended consequence of making more difficult efforts to extend their work into rural areas accustomed to the handywoman. Many rural patients proved resistant to exchanging the familiar assistance of the handywoman for the ministrations of a well-trained stranger who was prepared to fulfil only some of her responsibilities.
Reformer Elizabeth Malleson was among the first to confront the difficulties of replacing rural handywomen with district nurses. A Londoner from birth, as an adult Malleson had become an avid participant in various reform movements in the city, serving on the executive committee of the Ladies’ London Emancipation Society and helping establish Bloomsbury’s Working Women’s College, among other causes. When, after suffering a health crisis, she left behind her busy London life to move to a manor house in rural Gloucestershire, she brought the latest ideas about district nursing with her. As a newcomer to country life, she was dismayed to see continued rural dependence upon the handywomen, whom she called ‘rough ignorant women given to drink’.Footnote 20 In 1884, she established the Village Nursing Association with the goal of bringing district nursing to Gloucestershire, a first effort that transformed into the larger and more successful Rural Nursing Association (RNA) in 1889. Malleson ultimately modelled her approach after London’s MNNA, eager to extend the highest standard of urban healthcare deep into the counties. Her ideal district nurses were respectable middle- or upper-class ladies with hospital training and midwifery certification from the London Obstetrical Society.Footnote 21 Malleson’s admirable standards were endorsed by key leaders of the district nursing and midwifery registration movements, such as Florence Dacre Craven (first superintendent of the MNNA) and Zepherina Smith (founder of the Trained Midwives Registration Society).Footnote 22 Prominent support from urban experts did little to ease the translation of urban district nursing models into rural contexts, however.
In cities, district nurses typically shared communal homes, but in less densely- populated Gloucestershire, each nurse needed to cover a large district, making a central home impractical. Rural district nurses had to either live alone or board with a respectable family, thus raising the costs of lodging them. Urban district nurses often visited many different patients in one day, but travelling across large or rugged districts demanded considerable time, limiting the number of patients most rural nurses could reach. This logistical challenge was also a financial one: in the overcrowded neighbourhoods where most district nursing associations operated, the many small fees collected by nurses (together with a few donations from benevolent patrons) could in theory make a scheme self-sustaining. Fewer patients in rural areas meant fewer fees collected, making the dream of self-support a far-fetched one if the RNA hoped to afford nurses of the best training and class. As an added complication, country physicians sometimes viewed district nurses as an unwelcome source of competition for limited fees. To avoid conflict, many rural district nursing associations served a limited social spectrum of low-income patients, deepening their dependence on donations. It was donations from an impressive array of aristocratic women and other county elites that eventually enabled Malleson’s RNA to employ and supervise a growing number of rural district nurses.Footnote 23 New nurses were installed across the United Kingdom wherever interested elites were willing to help organise and fund a local association.
Even with significant philanthropic support, paltry £52 salaries made the recruitment of highly-trained lady nurses a serious challenge (the average female elementary teacher, for example, could make £76 in 1890).Footnote 24 In an 1889 letter to The Times on behalf of Malleson’s association, supporter Alice Dundas attempted to attract women wealthy enough to finance their own training and work for lower salaries as a potential solution. She invited ‘ladies of good birth and connexion’ with ‘some little means of their own’ to put aside their fear of ‘losing caste’ and undertake rural nursing, somewhat awkwardly acknowledging that the same social status that made lady nurses desirable might also make them reluctant to live and work amongst the rural poor.Footnote 25 Bertha Broadwood, who had been watching the troubled expansion of district nursing into the rural counties with interest, responded to Dundas’ letter to The Times by penning her own.Footnote 26 In it, she boldly challenged the notion that ladies with extensive training were desirable nurses for rural areas. She announced that since the early 1880s, she had been working on an alternative to district nursing that was far better suited to country life. ‘Le mieux est l’ennemi du bien’ was this movement’s motto, the anthem of the slightly trained nurse.Footnote 27
Perfect is the enemy of good: Cottage nursing
Bertha Broadwood was born in 1846 to a large family made wealthy through piano manufacture. Competent and opinionated, by the 1880s, Bertha Broadwood was a confirmed spinster in her 30s who was helping her father manage both his business affairs and Lyne House, the family estate in Surrey.Footnote 28 During her neighbourly visits around Surrey, Broadwood was ‘much disturbed’ to encounter many ‘broken-down women’ who seemed exhausted from caring for themselves and their families in times of childbirth and illness.Footnote 29 Like Elizabeth Malleson, Broadwood was inspired to investigate potential solutions to the apparent lack of trained nursing attendance. Unlike Malleson, however, Broadwood became convinced that district nursing was ill-suited to rural needs, which she insisted were ‘absolutely distinct’ from those of towns.Footnote 30 Broadwood believed country people had an innate ‘dislike of “towns-folks,” “strangers,” or “foreigners”’, that would make them resistant to unfamiliar lady nurses trained in distant hospitals. While this assessment perpetuated stereotypes that rural people were change-averse and insular, it also stemmed from Broadwood’s more progressive view that ‘local prejudices and predilections must be considered’.Footnote 31 In the early 1880s, she began to develop a nursing system with these ‘predilections’ specifically in mind. While sometimes her approach was called the ‘Holt-Ockley system’, it soon became more widely known as cottage nursing.Footnote 32
Cottage nurses were intended to step seamlessly into the well-worn shoes of the rural handywoman, infusing the traditional role of the domestic healer/helper with a modicum of modern training and sanitation. Broadwood recruited nurses from the ‘cottage’ class, seeking country women of ‘the roughest and humblest description’ who could be briefly trained and then returned to their communities. Any successful replacement for the handywoman, Broadwood believed, must be ‘a woman acquainted with hardship and suffering, who can sympathise with her patients’.Footnote 33 Such women would not only be able to relate to the difficulties of country living, but also be prepared to help shoulder the burden of them. Unlike a district nurse, who was generally responsible for all the patients in her own small ‘district’, each cottage nursing association typically employed a team of cottage nurses for all the parishes and communities within a given area. Having several nurses on hand meant that cottage nurses could work single cases continuously, staying with their patients overnight rather than paying shorter visits to many patients in a day. Nurses spent the time saved travelling from one patient to another minding children, cleaning house, or cooking. In exchange, patients lodged and fed the nurse, an arrangement that enabled her to subsist on a low salary of just £27.Footnote 34 So-called ‘benefit clubs’ supported nurse salaries by charging subscription fees that entitled patients to reduced fees for nursing visits. Subscriptions and fees were graduated by income, ranging from an annual subscription of 2s. for a labourer to 10s. for a member of the gentry class.Footnote 35 Attuned to the class subtleties of rural life, Broadwood kept detailed notes on what could be afforded by garden keepers, conductors, butlers, estate carpenters, tradespeople, and others who hardly classified as the ‘poor’ but still needed access to affordable nursing.Footnote 36 Fees paid by wealthier patients subsidised the cost of caring for their poorer neighbours, as did some donations.
In 1883, Broadwood employed the first three cottage nurses in Surrey. Like Malleson, Broadwood pursued the support of county elites to grow her association, keeping a list of ‘Some Ladies Actively interested in Cottage Nurses’ that included the names of five countesses, three viscountesses, and ten baronesses. Footnote 37 While the English counties of Sussex and Surrey would remain the epicentre of the movement, local associations sprang up wherever interested benevolent ladies or local committees employed a cottage nurse. By 1894, the movement had grown into the Affiliated Benefit Nursing Associations, thirty-six associations with a London information office and annual conferences. In 1906, affiliated associations were reorganised into the Cottage Benefit Nursing Association (CBNA). By the following year, there were over 700 cottage nurses working across the United Kingdom, from the Scottish Highlands to Western Ireland.Footnote 38
Broadwood envisaged cottage nurses as filling a gap in the patchwork system of rural healthcare emerging in the final decades of the nineteenth century. This system was uneven and had significant regional variation, but often included poor law institutions, public health authorities, cottage hospitals, district nursing associations, and country physicians.Footnote 39 Broadwood expected the destitute to rely on poor law institutions and those with serious conditions to call a doctor or travel to the nearest cottage hospital. This left the more mundane healthcare that pertained to being born, ageing, and dying, to her cottage nurses. Such views were overly optimistic considering how many patients still lived well beyond easy reach of either physician or hospital, but Broadwood rightly observed that many health problems did not merit expensive or advanced care.Footnote 40 Because many cottage hospitals and district nursing associations refused infectious cases for fear of spreading disease from patient to patient, Broadwood’s nurses were intended to fill this care void, accepting patients with tuberculosis, diphtheria, typhoid, influenza, and more. They also cared for elderly patients, many of whom had chronic, long-term conditions such as cancer or arthritis that were not suitable for hospital treatment. One cottage nursing pamphlet highlighted a cottage nurse who used ‘rubbings, fomentations and liquid food’ to treat a patient who had swallowed her false teeth.Footnote 41 At the other extreme of the life cycle, a clear majority of cottage nursing cases involved caring for mothers and babies.
The question of whether to provide midwifery services was one of the most heated debates surrounding rural nursing by the end of the century. On one hand, the dependence of rural patients on handywomen and other ‘untrained’ midwives in childbirth was a much-discussed topic amongst healthcare reformers; on the other, district or cottage nursing associations risked running into conflict if they offered cheap or free midwifery services that undercut the delivery fees of country doctors. Broadwood prized the support of physicians, claiming they preferred her deferential cottage nurses to district nurses emboldened by extensive training. For this reason, she initially envisioned her nurses as ‘maternity’ or ‘monthly’ nurses who tended to mothers postpartum but only acted as midwives in cases where the doctor did not arrive in time. This both saved the expense of giving cottage nurses midwifery training and avoided conflict with doctors. The reality was more complex: in areas where travel took longer and doctors’ fees tended to be higher, such as the Cotswolds and Scottish Highlands, cottage nurses sometimes acted as midwives (with or without certification), delivering the babies they more routinely cared for in the days following birth. In such cases, cottage nursing supporters reasoned that providing some form of trained assistance was better than leaving rural women to the care of the handywoman.Footnote 42 Sometimes, cottage nurses were likely former handywomen themselves, briefly trained as cottage nurses before returning to the communities they knew so well to continue the work they had always done.
Victorian nursing work was invariably difficult, but the work of cottage nurses was especially demanding, bridging sanitary, domestic, and nursing work. In an 1887 pamphlet she wrote to publicise her methods, Broadwood described a typical cottage nurse who had taken ‘entire charge’ of a ‘very dirty’ pregnant mother and her six children, nursing them through scarlet fever, disinfecting the cottage with lime-wash, and running the household for weeks.Footnote 43 In their surviving correspondence, cottage nurses sometimes reveal their struggle to cope with a preponderance of duties. One nurse, for example, complained that in addition to nursing a sick household, she had to feed the pigs.Footnote 44 Other nurses reported that their patients shared not only their humble fare but also the lice, bedbugs, or infectious diseases afflicting the household. In some cases, cottages were too small and crowded for the nurse’s cot, forcing her to sleep in a chair. In an illuminating letter, a hospital-trained nurse once rejected the offer to work as a cottage nurse, saying that ‘If the committee had the remotest idea what the work took…they would know that no woman in the world could do it’.Footnote 45 For Broadwood, this rejection was merely confirmation that the unglamorous labour of cottage nursing required unsophisticated nurses.
The women drawn to cottage nursing violated many of the ideals of those who envisaged nursing as a vocation for single, ladylike women that was modelled after religious nursing sisterhoods. Broadwood followed convention by requiring character references but frequently broke with many of the best practices of nursing recruitment. While many hospitals required nurses to live on-site in designated nurses’ residences and retire upon marriage, cottage nurses were free to live in their own lodgings when not on duty. This opened the field to widows, mothers, people with elderly parents, and other women with their own domestic responsibilities. Women with ‘common’ manners, poor education, or low social status were also not precluded. Rough, unpredictable, and operating in a world apart from the strict and hierarchical hospital, sometimes cottage nurses proved difficult for their local committees to manage. Association files contain multiple references to a Nurse Hurd, who indulged in unseemly ‘conversational familiarity’ with her social betters and disappointed their expectations. While nurses in the better urban hospitals were expected to assume a nun-like lifestyle of celibacy, Hurd once bawdily confessed that she had quite enjoyed having twenty teeth removed thanks to ‘the arm of the nice young dentist being around her neck’. Violating expectations for piety and decorum, she also committed the ‘outrage’ of ‘mimicking Holy Baptism’.Footnote 46
More gravely disappointing was the case of a married cottage nurse who became pregnant while on duty after having an affair with the bailiff of a local farm. Although Broadwood dismissed the nurse for having ‘fallen so disgracefully’, she also collected detailed information about the case in hopes of securing some accountability from the baby’s father. A follow-up letter from the disgraced nurse survives, discussing advanced wages, a ‘fat and rosy’ baby, and ‘comfortable’ surroundings apparently made possible by Broadwood, who tended to try to balance holding nurses to admittedly low standards with recognising how difficult their lives could be.Footnote 47 In 1887, Broadwood claimed to have only ever dismissed three women for having ‘failed in sobriety’, making the CBNA ‘no better and no worse off than any other nursing institution’. Although she expected sobriety from her nurses, she also acknowledged that the pervasive tradition of offering a nurse alcohol stemmed from how ‘hard and very unpleasant’ rural nursing work was.Footnote 48 The foibles and failings of her nurses were disappointing to Broadwood, but they posed a real problem when it came to finding institutions willing to train cottage nurses.
‘…very demented and unorthodox’: Training cottage nurses
Cottage nurses were bête noire to those struggling to dissociate nursing from stereotypes about the kind of women who had previously resorted to caring for the sick. This was especially true of the would-be gatekeepers of the profession, those running its top urban training facilities. Martha Vicinus notes that throughout the late nineteenth and early twentieth centuries, London’s main voluntary hospitals subscribed to the theory that ‘more is better’, pushing for ‘more years of training, more rigorous regulations, more discipline’.Footnote 49 Historians have pointed to the gap between ideal and reality, observing that many institutions that claimed to select only ‘lady’ nurses also accepted women from the lower middle and working classes.Footnote 50 Many cottage nurses, however, had still humbler origins that made them undesirable probationers. In her 1889 rebuttal to Alice Dundas’ efforts to recruit rural district nurses in The Times, Broadwood discussed her own struggle to find a training institution willing to accept her nurses. Although she had persuaded a London lying-in hospital to allow cottage nurses to attend some midwifery lectures, workhouse infirmaries and training hospitals refused to train them.Footnote 51 The problem was not just their humble social status, but also Broadwood’s vision that they have ‘not the long course leading to the perfection of the thoroughly-skilled hospital nurses’ but ‘training of a more limited time and character’.Footnote 52
Broadwood likened the idea of sending cottage nurses to London’s hospitals for a full course of training to ‘preparing a man for life on a savage island by a season in London’.Footnote 53 She resented a predominantly urban professional intelligentsia for failing to take her views on training seriously and bitterly lashed out in The Times, accusing London’s matrons of blindness to rural realities. ‘Possibly not comprehending the requirements of the country poor, they disapprove of anyone who has not been through a three years’ hospital course being called a nurse, and tell us that a little knowledge is a dangerous thing’, Broadwood fulminated, adding ‘At this rate, stop all elementary instruction. Away with ambulance and cooking classes! Ordain that every cook by profession must obtain the cordon bleu!’Footnote 54 In reality, nursing training varied widely at the time, and three years was far from being acknowledged as a universal standard. Most matrons and reformers agreed, however, that the mere three months of training Broadwood envisaged for her cottage nurses was grossly insufficient.
Broadwood’s breakthrough came when a fellow pragmatist who agreed that ‘some training was better than none’ read her letter to The Times and wrote to her offering to develop a training programme for cottage nurses.Footnote 55 The offer came from Katherine Twining, an unmarried daughter of a branch of the Twining tea dynasty who had been raised on a large estate in Ireland. Twining was a trained nurse who ran a London nursing charity and training institution known as ‘Plaistow’.Footnote 56 ‘Sister Katherine’, as she was often called, believed that ‘the idea of cramming all thro the Hospital mill’ was ‘most absurd’. Pushing back against those who hoped to universalise one standard of training, she advocated for ‘different grades’ of nurses who underwent different kinds of training. Twining believed that nurses destined to work in country cottages should receive ‘no Hospital training’ but instead receive instruction in the homes of actual patients.Footnote 57 In 1889, she wrote to Broadwood offering to train cottage nurses in the overcrowded East London suburb that gave Plaistow its name. The pair developed a barebones three-month training course for cottage nurses that provided hands-on instruction in the homes of the poor. While Twining also trained many midwives studying to take the London Obstetrical Society’s examination at Plaistow, she believed that, for cottage nurses, midwifery was ‘…a jolly good lot to learn in three months…and it would take better brains than theirs!!!’Footnote 58 The three-month course covered only basic nursing, sanitation, and postpartum care. It could be customised, however, lengthening to up to eighteen months based on the needs of individual probationers and the requests of those paying for the training.Footnote 59 Rural patronesses frequently requested that their cottage nurses also receive midwifery training to enable them to serve as more effective replacements for the handywomen.
From 1890 to 1897, Plaistow trained 563 women as nurses, midwives, or both, sending them to work in 28 counties and all four kingdoms.Footnote 60 It soon proved as controversial as it was popular. Twining and many cottage nursing supporters tended to view the three-month training as a necessary evil, one that would be obviated as patients or patroness saw the value of good nursing and were willing to pay more for it. ‘…I always say if we can get money enough of course we shall employ more highly-trained nurses. But are we to be debarred any nurses because we can’t have the best[?]’ one cottage nursing supporter wrote to Broadwood.Footnote 61 Others followed Broadwood’s lead in insisting that they had ideological reasons for employing cottage nurses. Millicent Leveson-Gower, Duchess of Sutherland, for example, claimed she had thoroughly researched district nursing before deciding to employ cottage nurses from Plaistow for her vast estates in Scotland instead. She maintained that this decision was not made as a cost-saving measure but because her tenants preferred ‘one of themselves, taken to be trained out of her native village, and returned to her native village with fresh experience and a midwife’s certificate’.Footnote 62 Proponents of district nursing tended to view such justifications with scepticism, seeing the employment of cottage nurses as clear evidence of either classism, greed, or both. In an 1893 paper written for a women’s congress, Elizabeth Malleson and Victoria Lambton criticised those who ‘wish to make their philanthropy as cheap as they can’ by hiring ‘ignorant and common women made doubly dangerous by a small amount of cheap and insufficient training’. The pair reaffirmed their belief that ‘no nurse is too good, too refined, and too high-minded for the work’ and voiced their support for a new national district nursing association that seemed to embody this philosophy.Footnote 63
The new standard-setters: The Queen Victoria’s Jubilee Institute for Nurses
In 1889, the Queen Victoria’s Jubilee Institute for Nurses (QVJIN) was established using donations raised in honour of the 1887 Golden Jubilee.Footnote 64 Spearheaded by a team of well-known nursing reformers and influential courtiers, this nursing association was from the outset far wealthier and more powerful than the nursing associations started by either Broadwood or Malleson. The Institute’s remit was extensive, providing district nursing to the United Kingdom’s ‘poor’, which it broadly defined as all those who could not afford a private nurse.Footnote 65 Heavily influenced by the MNNA, the Institute furthermore aimed to advance the highest possible standards of district nursing. It required its ‘Queen’s Nurses’ to have a minimum of one year of hospital training (increased to two years in 1893 and three in 1906) followed by six months of district training. In rural areas, they were also required to have midwifery certification. The QVJIN maintained an exclusive ‘roll’ of vetted Queen’s Nurses who met these criteria, most of whom came from middle-class families. The QVJIN also professionally inspected affiliated associations with the goal of keeping standards high and policies enforced. In short, exclusivity and rigour positioned it in diametric opposition to Broadwood’s vision of rural nursing. She forthrightly rejected the QVJIN’s proponents as ‘persons conversant with District Nursing in Crowded towns, but ignorant of the conditions and requirements of Country Cottages’.Footnote 66 Elizabeth Malleson predictably proved more receptive: in January 1891, her RNA metamorphosed into the QVJIN’s new ‘Rural Branch’. The QVJIN and former RNA subsequently joined hands in the campaign to convert the United Kingdom to the gospel of the ‘fully-trained’ district nurse.
While the QVJIN rapidly expanded across the United Kingdom, affording its exacting standards soon posed a challenge in many rural communities. The QVJIN vetted Queen’s Nurses and inspected them, but it did not pay for them; local committees had to guarantee the nurse’s salary, which ranged from £60 to upwards of £80 per annum. Where few fees could be collected, the cost of the nurse often fell to ‘the personal generosity’ of elites.Footnote 67 When charitable donations proved insufficient, the temptation to cut corners was strong. ‘There seems to me a good deal that is open to remark’, QVJIN president Arthur Peile observed of the Rural Branch in 1891, adding, ‘The qualifications of their nurses and the places of Training are I think somewhat doubtful’.Footnote 68 As the Institute grew, a more elaborate system of County Nursing Associations, each with its own committees and affiliation agreements, was developed to replace the Rural Branch. These, too, became notorious for bending rules.Footnote 69 Some associations that found they could not afford Queen’s Nurses quietly employed less thoroughly trained women. According to historian Enid Fox, the Institute also faced the ‘infiltration’ of some cottage nursing practices and ideas, such as allowing nurses to stay overnight with their patients.Footnote 70 At first, the QVJIN chose to ignore some small compromises, but by the mid-1890s, the QVJIN’s central council had to admit that a distressing belief was ‘gaining ground…that a half trained nurse in the Country is just as useful as one who is fully trained’.Footnote 71 Patients were proving maddeningly satisfied with inferior nurses, and this was a dangerous notion, one that significantly undermined the argument that nursing could only safely and efficiently be done by women qualified to an agreed-upon standard. The QVJIN’s fraught foray beyond urban centres was already forcing it to choose between its ideal of being a standard-setting district nursing association and its mission of making in-home nursing care available to all.
By the 1890s, Edith Finch-Hatton, Countess of Winchilsea, was one of many elite women across the United Kingdom considering the different options available for establishing a local nursing association. Winchilsea had passionate defenders of both district and cottage nursing in her social circles, but neither option seemed to her to be a perfect solution for her Lincolnshire community. When a writer for The Woman at Home magazine visited her at Haverholme Priory in 1895, he noticed a table strewn with papers regarding plans for a new kind of nurse. ‘Now my idea is to take village women, send them up to the training home for nurses at Plaistow, and then establish them throughout the country villages, where they are well known, to nurse the very class of people from whom they themselves are sprung’, she explained. So far, her description sounded exactly like cottage nursing, but Winchilsea claimed to have examined both the QVJIN and CBNA and ‘taken the good out of each system’ to create something new.Footnote 72 Winchilsea’s idea was a class of nurses who were more affordable than Queen’s Nurses but more thoroughly educated than most cottage nurses, especially in midwifery. The Lincolnshire County Nursing Association was the first to employ her solution, nurses trained for six months, certified in midwifery, and paid just £35–45 per year. The association insisted that its employment of Winchilseaʼs nurses was not because it was ‘satisfied with a low standard of training’, but because it acknowledged ‘the absolute necessity of employing two distinct grades of nurses if the poor (especially mothers and infants) and their wants are really to be considered before anything else’.Footnote 73
While normally the employment of such substandard nurses would preclude an association from affiliation, in 1895, the QVJIN not only affiliated the Lincolnshire County Nursing Association but also announced a shocking capitulation to its tactics: in rural areas, the QVJIN would henceforth employ both Queen’s Nurses and Winchilsea’s new ‘village nurses’. To Broadwood, the QVJIN’s new village nurses were a clear attempt to compete with her association while refusing to acknowledge the rightness of her ideas. QVJIN supporters seemed to her to be ‘jealous foes’ who lost ‘no opportunity of belittling our work’ while being ‘too proud to openly adopt any of our principles’.Footnote 74 The Institute’s apparent hypocrisy only deepened in her eyes when it began to train its village nurses at Plaistow, where Broadwood claimed they received ‘precisely the same training’ as her much-maligned cottage nurses with the simple addition of a midwifery course that extended their training from three months to six.Footnote 75 Her resentment grew as she sensed that the QVJIN was pressuring Plaistow to ‘give up the short course’ and only offer the six-month village nurse training. While Broadwood’s worries that giving cottage nurses six months of training would turn them ‘into grand ladies’ who refused to work in cottages were perhaps overblown, she did accurately sense she was fighting a losing battle against escalating expectations at Plaistow.Footnote 76 By the turn of the century, Twining discontinued the three-month training, forcing the CBNA to begin work on a new facility (Bury House, located in Edmonton) and send more of its recruits to other institutions.
To some, village nurses were clear evidence that the QVJIN had ‘departed from its original standard, and approves that much-scorned individual, the “half-trained nurse”’.Footnote 77 Almost immediately, the Institute began to attempt to mitigate the impact of its concession, pressuring those employing village nurses to train them for nine months, a duration it eventually extended to one year. The Institute restricted the availability of village nurses to only rural districts that could either not afford a Queen’s Nurse or already employed one. Despite such efforts to improve their training and limit their remit, however, by 1905, village nurses represented roughly one-fourth of the nurses employed by the QVJIN in England and Wales, and, as historian Carrie Howse has shown in her study of Gloucestershire, in some counties they represented more than half.Footnote 78 The QVJIN’s great concession to rural interests had clearly introduced competition for its own Queen’s Nurses. And yet, village nurses were imperfect competitors for cottage nurses. Critically, village nurses were discouraged from spending the night with their patients or assisting with more strenuous household labour – key issues to cottage nursing supporters. After a visit to Sussex in 1902, QVJIN general superintendent Amy Hughes observed that the conviction that ‘resident nurses with as little training as possible … are the best for the country poor’, had ‘permeated the whole county’. After seeing the area, she acknowledged that local geography, with ‘an endless series of long hills’ and ‘only field paths to hamlets and isolated farms’, lent credence to the practice of nurses spending the night with their patients.Footnote 79 Hughes later ignored the lapse in policy when she inspected some village nurses who also stayed with their patients overnight.Footnote 80
It seemed that one compromised standard had a way of leading to another, but the failure to compromise could also have unforeseen consequences. The QVJIN’s Irish and Scottish Branches both refused to employ village nurses, taking pride in their staunch maintenance of the Queen’s Nurse standard. Broadwood stood prepared to meet the demand created by their refusal to bend. In 1901, she assisted in the establishment of a Plaistow-like institution in Glasgow that supplied less thoroughly trained nurses to Scotland. Known colloquially as ‘Govan’ nurses, these women were cottage nurses by (yet another) name.Footnote 81 Some local committees and landowners also turned to cottage nursing in Ireland, where many communities were unable to afford Queen’s Nurses unless they were chosen as the beneficiaries of special charitable funds raised for this purpose.Footnote 82 In an unfortunate case, a special fund being used to pay for a Queen’s Nurse on Achill Island ran out. When the Institute announced its intention to remove the nurse, some of the islanders protested, penning a petition and writing to explain that losing their nurse would leave them ‘worse off than if we never had one’ since ‘a good many of the old handy women have given up or died’.Footnote 83 Broadwood had seemingly anticipated such situations in 1887, warning that ‘Perfection is an excellent standard, and progress is most important, but if pushed, or forced on too quickly, it thrusts much that is good aside into neglect, and disturbs a great deal without establishing anything better’.Footnote 84 Her criticisms of those who condemned the handywomen without guaranteeing a replacement made her a critic not only of the Scottish and Irish arms of the QVJIN, but also of midwifery registration, an idea that was only gaining momentum.
‘…progress is most important’: The Midwives Act (1902)
Population concerns peaked around the turn of the century, bringing increased significance to the midwifery services of many rural nurses.Footnote 85 As a political climate preoccupied with national strength gave supporters of midwifery registration fresh impetus, they frequently held up rural women as key beneficiaries of any moves to replace the ‘dangerous’ and ‘backward’ handywomen with trained nurses and midwives. The idea of requiring midwives to pass a certification exam and be enrolled on a national register was far from universally popular, however. Broadwood nurtured suspicions that many advocating for change were either shockingly ignorant of rural realities or grossly insensitive to them. She warned that legally targeting handywomen would create dangerous shortages of birth attendants if nothing was simultaneously done to both convince qualified midwives to work in sparsely populated communities and enable the rural communities to afford them. She observed that, despite arguments ‘that they only desire to safeguard mothers’, midwifery registration supporters were in fact putting some women ‘at a most cruel disadvantage’ by pushing for legal prohibitions on their only existing form of care.Footnote 86
After years of lobbying and failed attempts, the Midwives Act made registration a reality in England and Wales in 1902. In an effort to prevent the shortages predicted by Broadwood, the act was rolled out gradually. An eight-year grace period was allowed from 1902, during which women with no formal training could be registered as ‘bona fide’ midwives. Almost immediately, however, England and Wales were discovered to be far more dependent upon uncertified practitioners than most of the urban professionals and reformers who had taken the lead in advocating for the legislation had realised.Footnote 87 As the 1910 provision banning the unregistered from practice approached, calls for training more midwives became ever more urgent. In 1906 Rosalind Paget, the QVJIN’s representative on the new Central Midwives Board (CMB) tasked with carrying out the act, emphasised that ‘all who have at heart the welfare of the population in rural districts’ should be seriously questioning who would replace the handywoman.Footnote 88 Broadwood joined other concerned ladies on the committee of the Rural Midwives Association, a group that raised funds to train midwives to ‘supplant the untrained midwife whose reign is so shortly to cease’.Footnote 89 Privately, she considered it too soon to announce the end of this ‘reign’ given the ongoing succession crisis.
In 1907, Broadwood annotated the margins of a letter stating that uncertified women would ‘of course be debarred from further practice’ after 1910 with the words ‘But who will prevent them?’Footnote 90 As she predicted, some uncertified midwives continued to work illegally or exploited legal loopholes that allowed the untrained to provide emergency assistance.Footnote 91 Certified midwives had more incentive to practice in cities, where Irvine Loudon estimates that they could often expect to earn more than four times as much as a typical country midwife from midwifery fees. Footnote 92 Because many rural areas did not have populations large or pockets deep enough to support an independent midwife, the pressure on district and cottage nursing associations to employ nurses who were certified midwives intensified. Unsurprisingly, the most affordable (and briefly trained) nurses were the most in demand. From 1902 to 1910, the number of Queen’s Nurses doubled from 651 to 1307, but the number of village nurses swelled from 127 to 905.Footnote 93 The CBNA meanwhile began to certify more of its nurses as midwives, slowly lengthening and increasing the cost of the training of at least some of its recruits. By 1907, roughly a quarter of cottage nurses were certified, further blurring the already murky distinction between village and cottage nurses.Footnote 94
Unfortunately, using their new certification could be prohibitively expensive and risky whether the prospective midwife was a Queen’s, village, or cottage nurse: the new legislation required that those acting as midwives call physicians in cases of emergency or face prosecution. Some physicians took advantage of this fact, doubling their fees or refusing to answer if they were called by nurses or midwives.Footnote 95 Rosalind Paget spoke out against this practice in 1905, reporting data she collected for the CMB suggesting that doctors missed an abysmal one-third of births for which they had been booked in advance.Footnote 96 In this context, complaining of the ‘competition’ posed by a nurse came dangerously close to suggesting that leaving rural women with no care at all was preferable to permitting them the care of a less qualified competitor. Rumours of a few shocking cases of mothers dying when physicians refused to answer emergency calls doubtless made some long for the return of the handywoman, who had not taken her own professional self-interest so deadly seriously.Footnote 97 The act’s aftermath had uncomfortably exposed its mixed motivations, which included not only the safety of rural mothers, but also the professional interests of qualified midwives, nurses, and physicians. Unfortunately, these motivations sometimes proved incompatible, and the same rural mothers held up as the chief beneficiaries of better-trained practitioners remained beyond their reach.
Butter and Margarine: Nursing semantics and registration debates
In the aftermath of the successful passage of the Midwives Act, nursing registration bills brought before parliament each year from 1904 to 1914 served to intensify the debate over what kind of qualifications should be required of those who claimed the title of ‘nurse’.Footnote 98 As early as 1890, Broadwood had advised those trying to claim exclusive use of what had historically been a generic and flexible word to consult ‘Greek and Latin lexicons’ and find ‘a distinctive appellation’ for the ‘new species’ of hospital-trained women.Footnote 99 In 1904, a cottage nurse wrote to the British Journal of Nursing responding to recent suggestions that cottage nurses be called ‘home helps’. After defending her claim to the title of ‘nurse’, she added that it was ‘strangely small’ of better-trained women to begrudge cottage nursing to patients who would otherwise ‘be quite unable to secure any trained assistance’.Footnote 100 Prominent nursing registration supporter Ethel Bedford Fenwick, who also happened to be the editor of the journal, responded with a vigorous rebuttal: ‘Is a woman of the industrial class, who has had no hospital training, but has had four or six months’ experience of maternity work in a district, entitled to be described as a “trained nurse”? We think not…she is not a “trained” nurse in the universally-accepted interpretation of the word’.Footnote 101 The problem was of course that Bedford Fenwick’s definition of ‘trained nurse’ was still many a country mile from being ‘universally accepted’.
Debate at the 1909 Jubilee Congress for District Nursing in Liverpool broke simmering tensions over professional definitions into open controversy. Although the QVJIN hosted the event, many with competing approaches to in-home care made the trip to Liverpool, including Broadwood herself. In remarks entitled ‘A Standard Required’, Lady Helen Munro-Ferguson, wife of a Scottish member of parliament and sister to a Queen’s Nurse working in Ireland, unabashedly spoke in favour of the QVJIN’s Scottish Branch and its refusal to compromise its standards. ‘We never could see why, because persons live in an inconvenient, out-of-the-way district, ten miles or so from the nearest doctor, they should have a less experienced nurse than an individual who has a doctor next door’, Munro-Ferguson said.Footnote 102 Later, she abrasively likened village and cottage nurses to cheap ‘margarine’ being sold as ‘butter’ to patients with ‘undiscriminating taste’. Munro-Ferguson supported nursing registration, and she cited recent debates over the latest version of proposed registration legislation in her remarks. ‘We all know that there are no “ordinary ailments” reserved for any one class’, Munro-Ferguson said, quoting a parliamentarian who had suggested that one class of nurse was needed for ‘people who had important operations by eminent surgeons’, and another for ‘the ordinary ailments of the poor’. Suffering and disease were no respecters of persons, Munro-Ferguson contended, and neither should be nursing standards.Footnote 103
Munro-Ferguson’s forthright call for better definitions and higher standards elicited applause, but also spirited rebuttal from the many women who employed cottage and village nurses gathered at the event. ‘The best is good enough for everybody; that is an undeniable fact…but we must recollect that we cannot attain it’, one woman said. She urged her listeners to ‘drop for a moment the sentimental side, and look upon the business side’, considering that the only way to make the best nurses universally available without significant donations or governmental support was to drop their already low wages.Footnote 104 A letter read at the Congress from an association on the Scottish island of North Ronaldsay, Orkney, offered the perfect illustration of this point. On its surface, it was a passionate defence of the need for extensively trained nurses in remote areas. The island often had no doctor, meaning its Queen’s Nurse worked as doctor, nurse, dentist, and midwife, making full use of her excellent training. The letter also revealed, however, that it was ‘only because our nurse is willing to accept a salary much less than the usual one, that we are enabled to continue the work here’. As ‘a native of the island’, the kind-hearted nurse accepted poor pay. In a move that must have made district nursing supporters groan inwardly and cottage nursing champions beam with vindication, the letter closed with a plea asking the gathered delegates for donations.Footnote 105 It had simultaneously served as a demonstration of why excellent training was justified in rural districts and why it was so often unattainable there.
After the Congress, Broadwood wrote the QVJIN’s headquarters demanding an apology for how her nurses had been discussed at the event. She also aired her grievances in the Liverpool Courier, writing that ‘neither Lady Helen nor the nurses at the Congress, whom she roused to mocking laughter against their humbler sisters, have any notion of the remoteness of the dwellings that cottage nurses are often called to’.Footnote 106 A different version of the dispute appeared in the prominent nursing journal Nursing Notes. Although it conceded that the employment of ‘cheap’ nurses stemmed from ‘undoubted need’ and ‘very real difficulty’, it maintained that the problem was not ‘securing funds sufficient to support the fully trained “Queen’s Nurses”’, but ‘finding the fully trained women who are willing to take up the work in sparsely populated country districts’.Footnote 107 This was a convenient fiction, blaming the choices of thoroughly trained nurses rather than addressing the challenge of how sparsely populated or impoverished rural areas could ever hope to afford them. Like Munro-Ferguson, Nursing Notes was attempting to sidestep the question that CBNA supporters stubbornly refused to drop: when the satisfactorily trained nurse simply could not be obtained, would the nursing profession compromise some of its ideals or abandon some of its patients? In 1914, an unprecedented national crisis forced an answer to this question.
‘…perfectly scandalous in some cases’: World War One and registration
Nursing standards that had been endlessly debated over decades quickly fell by the wayside during World War One, dropped by a nation in the throes of crisis. With too few professional nurses trained to any degree to meet the demand, more than 19,000 British and Irish women volunteered to work in military hospitals full-time between 1915 and 1919, with ‘tens of thousands more’ working part-time.Footnote 108 The volunteers had a wide spectrum of training that ranged from a matter of days to a full hospital course. The focus of debate over minimum standards now suddenly shifted to this new group of ‘half-trained’ nurses. While it was difficult to justify sending any but the best-prepared nurses to care for the grave injuries of the empireʼs broken war heroes, maintaining strict standards would risk leaving soldiers unattended. The situation was impossible, as it had long been in many rural places.
Most women with the leisure and means to volunteer as ‘VADs’ (Voluntary Aid Detachment nurses), belonged to the social classes that many leading nursing reformers and matrons had long idealised and courted. In this sense, they fulfilled long-nurtured dreams that middle and upper-class women would eagerly flock to the profession. Rather than enhancing the profile of nursing, however, many feared these lady volunteers were undermining hard-fought professional gains by treating nursing as a pursuit that genteel women with empathy and intuition could excel at even without extensive training. In 1916, Katharine Furse, the Commandant-in-Chief of the British Red Cross Voluntary Aid Detachment, wrote to Broadwood identifying a parallel in the treatment of VADs and cottage nurses by some professional nurses. ‘If you can do anything to help us to prevent the really rather disgraceful behaviour of trained nurses towards VADs in many of the hospitals, you will never have cause to regret it’, Furse wrote, adding that the treatment had been ‘perfectly scandalous in some cases’.Footnote 109 Although most VADs now made them seem highly experienced in comparison, however, cottage nurses were also still the source of significant resentment. The British Journal of Nursing gave vent to outrage when the CBNA was asked to supply nurses to the War Office, reporting that ‘Nothing need surprise the nursing profession in these sad times, but that our heroes are to be subjected to the ministrations of “cottage nurses” … is the limit’.Footnote 110
Very few wartime records of the CBNA survive, so it is unclear how many cottage nurses reported for war service. The more complete records of the QVJIN indicate that the war proved a devastating competitor in the scramble for both personnel and donations. Many nurses left civilian nursing for more celebrated roles, forcing the Institute to ignore lapses in policy and make unprecedented concessions in some especially understaffed districts.Footnote 111 As the war dragged on, even the most inveterately generous nursing donors became more close-fisted. In 1918, Broadwood, increasingly distracted from her association by a struggle against declining health and the rising cost of living, was forced to recall a loan she had made to her own association.Footnote 112 A new threat also appeared on the horizon: despite the mounting difficulty of finding and funding nurses to meet domestic healthcare needs, in 1916, the College of Nursing (a coalition of influential voluntary hospitals and training schools), began to offer accreditation on a voluntary basis. This was an apparent step toward nursing registration.
Times were changing rapidly, and even an ageing Broadwood, who disdained the suffragettes and railed against ‘the imposers of unjust and unwise Income Tax’, acknowledged that her association had to adapt if it hoped to survive.Footnote 113 At some point before 1919, the CBNA quietly made the dramatic decision to lengthen its training for any new recruits to one year. This was a previously unthinkable concession, but CBNA supporters increasingly viewed registration as a foregone conclusion. They hoped that extended training would win them the protection of the College of Nursing, even though some registration supporters continued to advocate for a universal minimum of three years’ hospital training for all nurses.Footnote 114 At a 1916 CBNA meeting, Broadwood spoke of her wish that cottage nurses would be acknowledged via a ‘separate list’ with lower training requirements if the three-year requirement did come into effect.Footnote 115 In 1919, during the second reading of proposed nursing registration legislation, Captain George Bowyer echoed her plea, citing the potential impact of an overly high standard on the rural poor. ‘I am aware that I may seem to be pleading for a lower minimum standard of training’, Bowyer admitted, ‘but the Bill, I submit, considers the status of nurses in this respect perhaps to the disadvantage of the patient’.Footnote 116
In an 1887 pamphlet on cottage nursing, Broadwood had warned of an escalation of professional expectations, predicting that ‘what is held to be good to-day, will be condemned as bad to-morrow’.Footnote 117 Thirty-two years later, the same one year of training that had previously made Queen’s Nurses standard-setters proved insufficient to save cottage nurses from being legislated into extinction. The Nurses Registration Act (1919) required nurses entering the profession to have three years of hospital training at an approved institution before they could qualify for the general register. Separate registers with their own requirements were established for mental health, sick children, and fever nursing, and for male nurses, but not for rural nurses.Footnote 118 Denied their own register and insufficiently trained to qualify for the general register, this meant that in the future cottage nurses would no longer be ‘nurses’ at all. In a concession to those concerned about the many thousands of Britons who were dependent on the suddenly unqualified, the act allowed women already in practice who failed to meet new standards but had at least one year of training to register until 1923. As this deadline loomed, the country’s reliance on insufficiently trained women once again became frighteningly clear. A last-minute emergency amendment opened registration to those who lacked even a year of formal training, but the bona fide registration period closed shortly thereafter, leaving many to question what would happen now that, once more, new standards had been established in full awareness that many rural communities were entirely unprepared to meet them.Footnote 119
Some cottage nurses registered, while others who failed to meet the new standard simply continued working as unregistered nurses, something the act did nothing to prevent. While registration failed to rid the kingdom of cottage nurses entirely, however, they were duly demoralised by legislation designed to make their inferiority and insufficiency a matter of legal record. If they hoped to be registered, new recruits after 1923 had to be accepted to an approved training school. Probationers at these schools subsisted on salaries kept low in part to dissuade lower class women from training. While previously the training of cottage nurses had been subsidised by local associations and wealthy patronesses, heavy postwar taxation led many members of the aristocracy and gentry to cut their voluntary spending.Footnote 120 Census records indicate that the profession as a whole was furthermore becoming younger and that fewer married or widowed women were becoming nurses.Footnote 121 For all these reasons, supply of and support for the kind of women long attracted to cottage nursing dwindled. Fortunately, there was also at last a decline in the demand for their services.
During the interwar period, hospitals grew in primacy, removing more nurses from the home. An escalating struggle to staff hospitals with qualified nurses shifted much of the debate over less thoroughly trained nurses to these increasingly central institutions.Footnote 122 The government also grew in its willingness to bridge the gap between the nurse rural patients could afford and the nurse that professional elites, reformers, and government officials increasingly agreed they needed. Almost no CBNA records from the interwar period survive, but QVJIN records documenting the fate of village nurses are illuminating: Increased governmental support for health, along with the 1936 Midwives Act (which required local governments to provide midwifery services), made it possible for many associations to employ registered nurses with midwifery certification for the first time.Footnote 123 Enid Fox summarises the impact of the 1936 Midwives Act upon village nurses by saying ‘fully trained district nurse-midwives could replace their poor cousins and forget they ever existed’.Footnote 124 With their lesser qualifications and humbler social standing, it is likely that cottage nurses were even more dramatically affected by these changes. Certainly, their history has been even more thoroughly forgotten.
False prophets?
Bertha Broadwood did not live to see the passage of the 1936 Midwives Act. She died in 1935 after witnessing almost a century of nursing history, debate, and change. Years before her death, she had jotted down some notes for her own obituary, predicting posthumous praise for the ‘imagination, determination and perseverance and doggedness’ she had displayed in ‘organizing and carrying through a work which has practically revolutionised nursing in country districts’.Footnote 125 This proved to be her final unheeded prediction: neither the revolution nor the praise she foresaw materialised, and her death inspired almost no public recognition. Subsequently, cottage nursing faded into the footnotes of a history that was for many years written by her greatest critics.Footnote 126 Much like her opposition to women’s suffrage, Broadwood had backed the losing side of an important debate, outliving an alternative vision for the future of rural healthcare that was destined to become less understandable and defensible in retrospect. She had undoubtedly lost. But had she been wrong?
On the surface, the record of cut corners and inferior standards that characterises the history of cottage nursing is damning. Critics fretted that a tendency to compromise professional ideals in rural districts stemmed, at best, from economic constraints, and, at worst, from an appalling disregard for rural lives. They had ample ammunition for their concern: cottage nurses were cheap, barely trained, and sometimes doubtless earned their detractors’ charges of ignorance and incompetence. And yet, the records of Bertha Broadwood, her CBNA, and the many people who supported them leave a more conflicted view of cottage nursing. At key moments of national debate, pragmatic arguments about financial and logistical limitations worked together with descriptions of distinctive rural preferences and needs to present a compelling case for cottage nursing. As rural realities made the logic of cottage nursing supporters explicable, the moral high ground occupied by those seeking to universalise the highest healthcare standards seemed less secure. As district nursing spread across the British world, the same basic debate over whether rural areas demanded a second tier of less thoroughly trained nurses furthermore arose with remarkable consistency.Footnote 127 In instances where less thoroughly trained nurses were the only form of trained assistance available, even their most ardent detractors found it difficult to challenge the idea that something was better than nothing. Time and again, those situated on the geographic and professional margins of familiar debates called for compromise, echoing Broadwood’s warnings that the blinkered pursuit of perfection would prevent life-saving progress for rural people. When such warnings were ignored, it was those who refused to acknowledge pragmatic realities who appeared to disregard rural need, prioritising idealised standards or professional ambitions over the opportunity to extend the barest minimum of care to those who could afford nothing better – and who often asked for nothing more.
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