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Where was Florence Nightingale? Developing municipal health visiting after 1900 by Dr Pamela Dale

In this blog Dr Pamela Dale tells us about the history of health visitors and their relationship to Florence Nightingale.

Today health visiting is an elite branch of nursing: only registered nurses and midwives can train as health visitors. Nurses have dominated the profession for the last 100 years, and the histories of nursing and health visiting are closely linked. However, alternative models of health visiting were also promoted in the pioneering phase. Before World War One, Bradford employed Female Sanitary Inspectors as health visitors, while Huddersfield recruited women doctors for this role. Uncertainty about who to appoint also extended to what staff could and should do.

Florence Nightingale, a passionate believer in health education, made important contributions to the development of health visiting by distinguishing between treating and preventing sickness. Generations of health visitors have been inspired by her professional ideals. Leading practitioners like Cheryll Adams, regularly draw on Nightingale’s writings. Critics of the health visiting profession have also extensively quoted Nightingale.

Now, as much as ever, there is interest in Nightingale’s personal life, career, and legacy. There was, however, a period when she went missing. Between 1900 and 1914 – the years leading up to and following Nightingale’s death in 1910 – many local authorities appointed health visitors for the first time. They gave many reasons for this – but I have found no mention of Florence Nightingale among them.

Defining the Health Visitor role in Halifax

In the early years of the twentieth century, local health departments were led by Medical Officers of Health (MOsH). These doctors tended to credit their medical colleagues with key reforms, and their records suggest no engagement with nurses or nursing organisations at a local or national level.

Halifax Corporation, whose records I have examined in some detail, prided itself on being a progressive local authority. In 1902, councillors considered appointing a health visitor, but failed to act. They could not agree on what the job involved and who should undertake it. Using one of Nightingale’s classic tactics, the Corporation set out to learn more about health visiting in other parts of the UK by devising a questionnaire. This was circulated to more than 70 councils in 1907.

The results showed that there was a large number and variety of schemes in operation. Some health visiting staff were trained nurses, but others offered alternative qualifications. Several responses argued against appointing women with medical degrees for these roles, without giving any particular explanation – nor was there any analysis of the connection between nursing and health visiting.

The Maternity and Child Welfare Act (1918) aimed to standardise services. Nursing gradually became the main, and then the only approved route into municipal health visiting. Places like Exeter, which had started their health visiting service later (1916) than Halifax and always relied on nurses, managed these changes better. Exeter City Council records reveal none of the anxiety about appointments shown in Halifax. Officials seemed confident that they knew who a health visitor was and what she should do.

Returning to Nightingale

However, operating the service proved complicated in practice. Problems of staff recruitment and retention persisted in both Exeter and Halifax throughout my study period (1906-1974). Difficulties with role conflict and role confusion were always apparent in local records. By the 1970s these topics were central to contemporary and historical accounts of health visiting. Supporters and critics of the profession covered similar ground but reached few conclusions.

It was at this stage that nurses and non-nurses started to draw on Nightingale’s work. Her writings, especially the emphasis on selfless vocation, allowed exploration of the high ideals of the profession. This was important when practitioners in the 1970s and 1980s were struggling with negative publicity resulting from major child abuse inquiries.

For some, Nightingale’s complex personality provided insights into the dilemmas of health visiting past and present. In their 2003 book, Anne Kelly and Anthea Symonds argued that while Nightingale’s contribution to the history of the profession is undisputed, her legacy is problematic. They suggested that the twenty-first-century profession needs to both celebrate the ideas of Florence Nightingale and move on – and they are by no means the only authors to do so.

But if Nightingale remains central to debates about the nature of the health visiting profession today, why was she absent from the same debates in the Edwardian period, when she was still alive? In part the explanation is that the records were created by doctors. Nurses didn’t get a look in. However, the work of local MOsH was also severely constrained by the demands of the Local Government Board and later the Ministry of Health. Edicts from Whitehall conveyed the thinking of politicians, civil servants and government medical officers – but offered no ideas from, or contacts with nurses or health visitors. It was only later that the maturing profession of health visiting found value in publicly debating Nightingale’s life and legacy as a guide to past, present and future practice.

Can you help research this topic?

Our understanding of the profession remains limited by gaps in the literature. The attention given to health visiting at different times and in different places varies. Little is known about individual practitioners. I would be interested to hear from anyone with information about early-twentieth-century health visitors.  Pamela Dale can be contacted via her University of Exeter email

A longer version of this blog (edited by Richard Bates), was originally published as part of a series to commemorate Nightingale’s bicentenary. For further details see Florence Nightingale Comes Home for 2020 [www.florencenightingale.org/abouttheproject/about-the-project.aspx]. The blog draws on research that was generously supported by the Wellcome Trust, grant O74999.

References / Further Reading

Adams, C. (2012), A paper on the History of Health Visiting, https://ihv.org.uk/about-us/history-of-health-visiting/a-paper-by-cheryll-adams/.

Dale, P. (2020), ‘The contested appointment of the first Halifax health visitor: exploring the importance of local as well as national debates in the Edwardian infant welfare movement’, Transactions of the Halifax Antiquarian Society.

Dale, P. (2020), ‘Health visiting between the wars: using fragmentary biographical data to explore attempts to resolve a developing recruitment and retention crisis’, UKAHN Bulletin, 8 (1).

Dingwall, R., Rafferty, A. M., and Webster, C. (1988), An Introduction to the Social History of Nursing (London: Routledge), chapter 9.

Kelly, A., and Symonds, A. (2003), The Social Construction of Community Nursing (Basingstoke: Palgrave Macmillan).

Biography

Dr Pamela Dale, is an honorary fellow at the University of Exeter. She has published a number of articles exploring various aspects of the history of health visiting and has also researched topics relating to institutional care. Together with Professor Anne Borsay, Pamela edited Mental Health Nursing: The Working Lives of Paid Carers (2015) and Disabled Children: Contested Caring, 1850-1979 (2012).

Image credit: Infant weighing machine, London, England, 1890-1930. Credit: Science Museum, London. Attribution 4.0 International (CC BY 4.0) https://wellcomecollection.org/works/nn98a8pb