Mental health nursing: The working lives of paid carers in the nineteenth and twentieth centuries

By Manchester University Press

This book seeks to integrate the history of mental health nursing with the wider history of institutional and community care. It develops new research questions by drawing together a concern with exploring the class, gender, skills and working conditions of practitioners with an assessment of the care regimes staff helped create and patients’ experiences of them. Contributors from a range of disciplines use a variety of source material to examine both continuity and change in the history of care over two centuries. The book benefits from a foreword by Mick Carpenter and will appeal to researchers and students interested in all aspects of the history of nursing and the history of care. The book is also designed to be accessible to practitioners and the general reader.

• Language: English
• Publisher: Manchester University Press
• Release date: Jul 1, 2015
• ISBN: 9781784992163

Book preview

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Mental health nursing: the working lives of paid carers from 1800 to the 1990s

Anne Borsay and Pamela Dale

At the beginning of the twenty-first century mental health issues are being debated at a local, national and international level.¹ Positively, there is an argument that the global promotion of mental well-being will deliver benefits ranging from personal fulfilment to improved public health. Yet there remain significant concerns about the social and economic costs of mental illness, which fall on individuals, families and communities. Interestingly, recent international and country-specific policy documents outlining the future of mental health provision have also offered an historical analysis to explain the current configuration of services and their limitations.² What has often been missing from these discussions is any mention of paid staff and their contribution to providing and transforming different models of care. We argue that this important omission is explained by both the traditional powerlessness of rank-and-file caregivers and the fragmented state of the historiography.

The history of care has had relatively little to say about paid carers,³ and within the history of nursing mental health tends to be neglected. Writing in 2009, Peter Nolan was only able to identify six significant historical studies of mental nurses and these included a thesis, three journal articles, Mick Carpenter’s Working for Health and his own classic history from 1993.⁴ There are other publications that touch on relevant issues, but these can offer a misleading picture of the role and achievements of the mental nurse. Compared to other branches of nursing, the mental health sector lacks even celebratory histories of Victorian/Edwardian nursing personalities and autobiographical accounts of working as a twentieth-century nurse. Scholars have identified a lack of detailed understanding about the recruitment,⁵ training and working lives of paid carers as both a serious problem and a vital agenda for future research.⁶ This volume develops new research questions by drawing together a concern with exploring the class, gender, skills and working conditions of practitioners with an assessment of the care regimes that staff helped create and patients’ experiences of them.

The chapters are arranged chronologically and concentrate on care in Great Britain and Ireland. This geographical coverage follows established literature conventions for the Victorian and Edwardian periods,⁷ and the transfer of personnel and ideas continued throughout the twentieth century. It is, however, not our intention to offer a detailed survey of legislative developments in either country. Similarly, Lee-Ann Monk’s chapter explores a colonial perspective on British models of staff training rather than providing an overview of psychiatric services in Australia. The aim is to focus on the rank-and-file staff whose role is often overshadowed by historical assessment of contributions from policy-makers.

Staffing issues have received most attention in the mental health sector, but significant insights have also been developed from the care of people now understood to have learning disabilities. Over time there have been significant changes in the language used to describe patients in both sectors but, to retain the focus on carers, tracing the evolution of terminology is not a central theme of this volume. Instead all the contributors have used language appropriate to their case studies, and here we apologise for any offence caused by obsolete words. Across the volume the term ‘mentally disordered’ is used inclusively to extend coverage from carers of patients with a formal diagnosis of a major mental illness to a variety of care settings where staff supported a range of service-users. Where it is necessary to distinguish between the sectors we have adopted the language of mental health/illness and learning disability services but it is important to remember that efforts to alleviate the distress of individuals were not confined to the care of people who had received a formal diagnosis or were following a conventional patient career. John Welshman (chapter 9) examines the care provided in hostels, concentrating on the Brentwood Recuperation Centre for Mothers and Children. The warden’s role in offering comfort and support, building resilience and rehabilitating clients in the community parallels many other contemporary mental health projects while also revealing the perceived benefits of smaller-scale facilities and personalised services. The therapeutic value of relationships established between staff and residents, emphasised in chapter 9, arguably applied in all the care settings described in this volume.

Such a conclusion helps integrate the recently restated concerns of nursing historians,⁸ perhaps preoccupied with the priorities of general nursing, with ongoing research exploring the care of the mentally disordered from a variety of perspectives. Classic history and social history of nursing texts by Brian Abel-Smith,⁹ Celia Davies,¹⁰ Christopher Maggs¹¹ and Dingwall, Rafferty and Webster¹² provide a framework for understanding the earliest origins of nursing; the evolution of different branches of nursing; attempts to define and improve nursing knowledge and practice; efforts to improve training and raise standards as a pre-requisite for professional recognition; the aspirations of nurse leaders; the consolidation of nursing organisations; and the changing place of the nurse in society.¹³ Scholars from different backgrounds have contributed to the historiography, but although collective knowledge has widened and deepened since the 1980s, they have generally worked within the established parameters of nursing history. This approach has served to prioritise certain topics at the expense of others, with care of the mentally disordered often neglected despite evidence of public concern about the past, present and future of these services.

The emergence of modern nursing is usually dated to the mid nineteenth century. It is generally agreed that its complex evolution and international variations were shaped by the relationship between nursing and the state, religious influences, economics, a concern with social welfare, class and gender issues, scientific innovation, medical change, the reform of hospitals and the development of a distinct body of nursing knowledge.¹⁴ Such analysis, in the UK, tends to prioritise the experiences of the general nurse in institutional and community settings with special status conferred on military nurses and the religious.¹⁵ It also foregrounds the goals elite nurses pursued through nursing organisations that claimed jurisdiction over rank-and-file practitioners but whose historic policies discriminated against those who were not white, female, middle-class, London-based and trained in a prestigious voluntary hospital. Within these discussions the asylum attendant (later registered mental nurse (RMN) or psychiatric nurse, or registered mental handicap nurse (RNMH) or learning disability nurse) tends to be overlooked or described in a way that suggests inferiority to the general trained nurse.

An early account of mental nursing within the history of nursing written in the 1930s drew a distinction between the few trained nurses in the sector and the many untrained attendants. The trained nurses were further divided into those who had completed a three-year course leading to admission to the supplementary register of mental nurses and those who had taken Royal Medico-Psychological Association (RMPA) qualifications.¹⁶ Similar themes inform Dingwall, Rafferty and Webster’s 1988 survey. Although they make the interesting point that ‘the fortunes of mental nursing have been intimately linked to those of the mental sector as a whole’, their presentation of asylums and their staff as both marginal to the concerns of the wider nursing profession and something of an embarrassment to health care providers imposes its own restrictions.¹⁷ It is certainly a perspective that neglects to consider the appropriateness of general hospital attitudes and practices to the care of the mentally ill, the special qualities and specific skills that might be demanded of the asylum attendant/nurse,¹⁸ and the distinctive problems presented by their working environment over more than two centuries.

Under the modern imperative to remove barriers between health and care services it is helpful to re-evaluate the historical contribution of those caring for the mentally disordered and break some of the shackles of traditional nursing history; this might be characterised as too

•  concerned with the story of professionalisation;

•  preoccupied with elite figures and national organisations;

•  focused on the female nurse and the ambiguous position of the male nurse;

•  stereotypical when discussing class and race; and

•  Whiggish.

Such organising points also speak to the institutional/psychiatric histories that have tended to neglect individual staff to concentrate on staffing problems. Within these debates the staff generally remain anonymous and are often treated as a homogeneous group. Contributors to this volume instead suggest that caregivers had a variety of experiences that depended on time, place, institutional politics and their personal place in various hierarchies.¹⁹ Current concerns about both the costs and public-safety implications of supporting large numbers of vulnerable people in the community provide a useful backdrop to a reassessment of historical models of care and the important, though changing, contribution of the mental nurse and other paid carers. The idea that nurses’ needs and experiences can shape their responses to patients, and thus wider care regimes, is only just gaining credence in the historiography but is the starting point for this collection of essays.²⁰ Troughout this volume there is a focus on struggle and unresolved tensions. The asylum attendant/mental nurse confronted many of the same issues driving the development of modern general nursing, but often differently. Relationships with local and central government were unusually important, and so was the style of medical management operating in the asylums. These themes have been central to the study of asylums, but within this historiography caregivers tend to be overlooked, with only brief discussions about their status as victims (of poor working conditions) and oppressors (of patients).²¹

It is, however, difficult to argue that mental nurses achieved any of the ‘three main attempted transformations’ of nursing described by Carpenter.²² They were not nurses in the Nightingale model, nor were they straightforwardly part of the later professionalisation or new professionalism agendas. Concerned commentators have identified that mental nurses are at great risk of workforce deskilling because of both their historical position at the margins of the profession and the content of their work, which pushes them towards a posture of providing care and control rather than cure.²³ Similarly, in an overview of staffing in the learning disability sector, Mitchell and Welshman place workforce issues ‘in the shadow of the Poor Law’ and highlight continuities between past and present obstacles to developing a well-trained workforce.²⁴ Such themes resonate strongly in all the case studies that follow, but nevertheless it is helpful to highlight different eras.

In the beginning

Caring for the mentally disordered is an issue that faces all societies, but the institutional paradigm is so dominant that the history of mental nursing often begins with this model. Nolan is one of many scholars whose survey of UK provision starts with the care offered by monks and nuns before the dissolution of the monasteries.²⁵ Positive connotations are attached to the refuge offered by these religious communities and he is not the only commentator who views their loss with regret. The problem is tracing what happened afterwards, as care of the mentally disordered, such as it was, is not well understood until the eighteenth-century rise of the private madhouse created a new institutional locus of care and concern. Such commercial provision ranged from the excellent to the purely exploitative, but early efforts to reform institutional care underlined the importance of good management and attention to staffing issues as the best guarantor of compassionate care for patients from all walks of life. Such concerns informed the development of public asylums, although patient numbers, financial constraints and staffing problems challenged the lofty aspirations of their founders.

Historians from many disciplines have highlighted the complexity of the asylum world, drawing attention to both problems of internal organisation and the difficulties imposed by external social, economic, political and demographic pressures.²⁶ Yet many medical superintendents regarded themselves as reformers, seeking enlightened as well as efficient models of patient care. Therefore close attention was paid to recruiting, training, deploying and disciplining staff conceived as keepers, attendants and finally nurses. Perhaps to a greater extent than in any other branch of nursing, the asylum attendant is seen as the creation, even prisoner, of his or her institutional context. Yet employing men and women to provide care for mentally disordered people was commonplace before a network of large public asylums was created, and the operation of these facilities always depended on ongoing arrangements for community care.

While it is easy to denigrate the motivations of paid carers and the quality of their care, they were nonetheless important. It is probable that many of these caregivers were originally domestic servants who offered care alongside or as an alternative to undertaking other household duties. The gradual specialisation of the role is highlighted by the way Poor Law authorities and societies providing the first cohorts of district nurses employed ‘nurses’ to care for the mentally disordered.²⁷ This work developed after 1850, but historians usefully identify an earlier tradition of ‘mad nursing’.²⁸ R. A. Houston was struck by the number and variety of people, of both sexes, receiving payment for caring for mentally disordered individuals during the long eighteenth century. He argues that these individuals ‘performed a role which blended the abilities of school teachers, jailers and lodging-house managers’.²⁹ The demands made on such carers were clearly considerable but social historians have been more concerned with assessing the burdens placed on relatives and factors that encouraged them to seek extra-familial support. It is the rise of the asylum that dominates the historiography and while this had an obvious impact on those seeking employment as caregivers, it seems unsatisfactory, in the light of the discussion above, to simply assert, as Kelly and Symonds do, that keepers ‘responsible for the containment of the mad … were seen as being of a dangerous nature themselves’.³⁰

It is important to differentiate between the experiences of senior staff, enjoying wide-ranging responsibilities, and policies affecting rank-and-file caregivers who were understood to require careful supervision to compensate for alleged personal and known organisational deficiencies. While staffing difficulties emerge as a perennial problem in asylum histories it is important to acknowledge the care that was taken with staffing issues. Most new public and charitable asylums started with the deliberate intention of recruiting a cohort of experienced senior staff from reputable institutions. These individuals must have brought with them attitudes and practices learnt from past service and even formal training. Nolan highlights the contribution of W. A. F. Browne (medical superintendent at the Royal Edinburgh Asylum) who he credits with introducing a pre-Nightingale nursing school.³¹ The personal example and writings of John Conolly (medical superintendent at Hanwell Asylum, Middlesex), who Steven Cherry credits with identifying the therapeutic potential of the mental nurse,³² also influenced practice in the UK and abroad (chapter 2). In the learning disability sector, the famous Earlswood institution provided a source of staff when provincial groups established similar facilities. Personnel appointed to new or reconfigured services were also sent to leading institutions for periods of training.

These imported and/or specially trained senior staff then instructed their juniors, who had opportunities to develop their careers by progressing through an institutional hierarchy, moving to another asylum in search of promotion, or utilising their skills and experience in other settings. David Wright captures the sophistication of the asylum labour market in Victorian London,³³ although historians concerned with rural institutions have been less enthused by the quality of available recruits, noting that into the twentieth century most newcomers were fairly raw domestic servants and farm labourers. The lack of trust these staff commanded is revealed by the care taken to enforce asylum rules (chapter 2) and sanction workers who challenged their employers (chapter 5). The surveillance exercised over junior staff was at least as intense as the watch kept over patients; indeed the former served to guarantee the latter. Obedience was seen as a necessary virtue for all nurses but the culture of suspicion that infected the asylums was a distinctive feature of a unique working environment that was as attractive to some as it was repellent to others.

Analysis of British asylum work continues to focus on power and its abuse, although few commentators go as far as Shula Marks’s devastating critique of asylum nursing in South Africa.³⁴ This leads to questions about what would attract people to work in such environments. While a sense of vocation, and a determination to care for others regardless of cost to self, imbues accounts of general nursing, mental health nursing has always been associated with an economic imperative. Yet this does not imply that practitioners had no alternative employment options. The decision to embark on what for many was intended as a career rather than simply a temporary job was a matter of deliberation and the careful cultivation of appropriate attitudes as well as the acquisition of valuable skills and experience. Far more attention needs to be paid to who was nursing at different times, and how this influenced their practice in terms of relations with patients and relatives and other health professionals, as well as caregivers’ views of themselves both individually and collectively. Notions of a shared experience enjoyed or endured by patients and staff, whose backgrounds were often surprisingly similar, are only just beginning to be explored. This means potentially illuminating concepts such as the idea of shared or transferred stigma and discussion about the fear of the contagious nature of mental illness have not been fully exploited. Even where a theoretical discussion is introduced, personal testimony is often lacking.

The historiography arguably needs to be more imaginative in terms of themes, approaches and sources.³⁵ Oonagh Walsh (chapter 2) emphasises the importance of language and culture as well as economic factors in shaping both demand for care and care regimes. Evidence that violence towards self and others was a factor encouraging resort to institutional care serves to reinforce the idea that paid carers took over at the point where care/control needs were most difficult to meet. Yet decisions about when and how to seek assistance, and the form any help might take, were heavily dependent on local factors that determined access to different institutions. Walsh’s interest in national politics as a framework for the provision of care contrasts with the often narrower scholarly assessment of the politics of nursing and nurse organisations.³⁶ Chapter 3 moves from the national to the trans-national and contributes to growing interest in international comparative work on the care of the mentally ill.³⁷ Lee-Ann Monk examines the influence of British models of care on a doctor-led initiative to professionalise the asylum attendant in late nineteenth-century Australia. Arguing that ‘attending’ is better understood as an occupation in its own right, rather than a precursor to the later profession, she discusses how the development of the occupation, itself influenced by earlier notions of ‘governing’ the attendant, shaped the attendant response to training and questions what benefits it had for staff or the people in their care.

Using international case studies to highlight the strengths and weaknesses of UK models of nursing as well as to consider their utility in different national contexts has already proved illuminating. Judith Godden and Carol Helmstadter make a number of important observations about Nightingale nursing in the light of contested attempts to transport it to colonial Australia and Canada.³⁸ Mental nursing opens a rich new field of enquiry but it is important to retain a focus on its distinctive features. These arguably became more important, and certainly received more scrutiny, in the early twentieth century. Contributors to this volume draw attention to the unusual gender composition of the workforce, the rise of trade unionism and the opportunities and constraints that followed from the traditionally close relationship between asylums and the state.

The First World War and its aftermath

A series of UK case studies (chapters 4–6) explore a crucial turning point in the history of nursing at the start of the twentieth century. At this time the general nurse was in the ascendancy, a cause and effect of the battles over nurse registration, and class and gender conflict was particularly acute. Wartime conditions 1914–18 threatened (through the use of Voluntary Aid Detachments) but ultimately consolidated the position of the general trained nurse.³⁹ In the mental health sector the suffering and sacrifice of asylum staff during the war years (chapter 4) fed industrial discontent (chapter 5) and the rise of trade unionism (chapter 6). In most accounts the attendants are treated as unremarkable with few clues given about their identities or personalities. This makes the personal testimony offered by Barbara Douglas (chapter 5) particularly valuable as she reveals how the Exeter strike, which sought to promote unity within the asylum workforce, resulted in disproportionate penalties for the long-serving male staff. Gendered aspects of asylum work have been persistently, though somewhat problematically, highlighted in studies of both asylum and nursing history. When contrasting asylum and general nursing, the presence of significant numbers of male staff has been both noteworthy and associated with distinctive work cultures, attitudes and practices. In particular male staff have been linked to a commitment to trade unionism, which embodied a collective identity that was different from the corporatism offered by the Royal College of Nursing.⁴⁰

Vicky Long (chapter 6) draws attention to growing tension between evoking sympathy for staff and patients on the basis that both groups had to share an unacceptably grim environment and the idea that attendants deserved improved pay to compensate them for the inhumanity of their charges. Ideas of shared citizenship were therefore deeply problematic and an obstacle to achieving the aspirations for better care that lay behind the 1930 Mental Treatment Act. Ambivalence about the aims and methods of treating mental illnesses in traditional or new ways was not confined to rank-and-file attendants or leading figures prominent in trade union and professional bodies. It also deeply infected the medical profession in a way that was highly problematic for all asylum staff. There was a danger that professional ambitions could either nullify the benefits of therapeutic innovation or endanger patients. Edgar Jones and Shahina Rahman critically reviewed claims that plans to make the Maudsley a preeminent centre for postgraduate medical education took precedence over meeting the needs of local people requiring mental health services.⁴¹ Unfortunately, they had little to say about how nurses adapted to the possibilities and constraints embodied in this new facility, but at the Maudsley, and elsewhere, the contested introduction of new physical therapies impacted on both the daily work and career prospects of mental nurses before and after the creation of the National Health Service (NHS).

The increasing resort to physical therapies, such as insulin coma or ECT, from the 1930s is associated with a requirement for mental health nurses to adopt the techniques and intensive nursing regimes previously associated with the care of the physically ill. These developments were accompanied by staff changes, with more dual-qualified nurses entering the mental hospitals and taking senior positions. This unsettled traditional hierarchies, while stifling debates about the distinctive needs of the mentally disordered and their carers. It also undervalued the skills of experienced mental health practitioners. Asylum staff had always monitored the physical and mental condition of their patients and managed difficult conditions such as epilepsy. They also understood the importance of nutrition and the therapeutic use of drugs and alcohol. Frank Crompton reminds us of the curative potential of the Victorian asylum and the vital contribution nursing care made to the treatment as well as the welfare of individual patients.⁴²

Debates about who should care and what that care should entail were played out in the interwar learning disability sector as well as the mental hospitals. Here the early development of community care programmes conflicted with trends towards a more medical and custodial approach.⁴³ Pamela Dale (chapter 7) explores how plans to offer more treatments placed new demands on male and female staff from the late 1930s. As the nursing staff expanded, new hierarchies were created and there were opportunities to import nurses and nursing knowledge from general and mental hospitals. This did not necessarily improve patient care, and staff turnover and disciplinary cases noticeably increased. These interwar tensions were exacerbated by wartime disruptions and reorganisations following the 1946 National Health Service Act.

The National Health Service

Despite its unifying national structures, the NHS did little to challenge the isolation of the mental hospitals while perhaps making them less central to what Joan Busfield terms ‘social networks of care and custody’. She identifies a four-stage development of welfare regimes in the mental hospitals from 1890–2004, characterised by calls for voluntary admissions (1890–1929), the Mental Treatment Act’s emphasis on more active therapeutic interventions (1930–53), a new reliance on psychotropic drugs and first steps to community care (1954–73), and the retreat of the state in the face of privatisation since 1974.⁴⁴ Nationally, nursing staff tended to respond to rather than initiate these developments. Yet these changing and often problematic contexts for service delivery led to almost continuous discussions about who should nurse and what skills practitioners required.

The NHS began at a time of severe staff recruitment and retention problems. Claire Chatterton (chapter 8) notes that the crisis in mental nursing was more severe and protracted than the oft-discussed shortages of general nurses. This point has also been highlighted by Starns who suggests that not only was insufficient care paid to maximising the recruitment and retention of people (especially men) with relevant wartime skills and experience, but arrangements to provide qualifying courses actively discriminated against those wishing to work in the mental health sector.⁴⁵ Many commentators drew attention to the armed forces as an important route into nursing for male staff in the decades after the Second World War, echoing nineteenth-century asylum recruitment patterns that had provided a supply of fit and disciplined recruits well-placed to make a long-term career in the sector. However, the arguments put forward in the 1960s and 1970s to suggest that more men should be recruited into general nursing confirmed their second-class status based on gender, pre-training experiences and association with mental hospitals.⁴⁶ No effort was made to delineate any special skills they might bring to the role despite an earlier debate about this in the USA.⁴⁷ Yet only a few years later it was noted that male nurses across all branches of nursing were enjoying career progression and success as nurse managers.⁴⁸ These issues kept gender discrimination, against women as well as men, on the nursing agenda through the 1970s and 1980s but did nothing to raise the status of mental hospital work.⁴⁹

From the beginning of the NHS era services for the mentally disordered had been destabilised by administrative and financial reforms that problematically interacted with the legacy of service provision, changing therapeutic dynamics and a need for legal reform. These issues came to prominence at different times but a perennial problem was staffing difficulties, which negatively impacted on both patient care and efforts to recruit and retain quality personnel. Mental nursing was not immune from the social and economic forces undermining traditional nurse recruitment strategies and suffered from the fact that its most modern and technologically advanced treatments could be perceived by patients to be abusive rather than therapeutic. This critical narrative imbues the historiography,⁵⁰ but an interesting personal account of receiving such treatments c.1950, informed by the author’s own nursing experiences and her obvious sympathy for both staff and patient perspectives, is offered by Claire Rayner.⁵¹ Other practitioners have come forward to share personal experiences of being a nurse, then a patient, and then attempting to resume a career after treatment for mental health problems. The fact that many chose to do so anonymously points to the stigma and difficulties they encountered.⁵²

Even today it is noteworthy that while nurses are seen as an important resource when promoting mental health and caring for the mentally ill, nurses are also understood to be vulnerable to episodes of mental illness and have a known occupational risk of suicide linked to access to drugs.⁵³ Stress has been identified as a major twentieth-century problem for nurses as well as their patients.⁵⁴ Since the 1950s a voluminous historiography has laid bare the challenges faced by nurses as members of a caring profession,⁵⁵ but also sought to individualise many of the suggested coping strategies rather than address underlying workforce issues. Service to others was strongly associated with self-sacrifice during and immediately after the Second World War and nurses-in-training were not expected to complain about their own conditions or on behalf of their patients.⁵⁶ Starns has usefully identified cultural and organisational problems in the newly created NHS that burdened junior staff with both excessive workloads and bullying seniors.⁵⁷ Over time, however, it became understood that the altruistic goals of the NHS were underpinned by the exploitation of certain staff and the neglect of vulnerable patient groups. Concerns about ‘Cinderella’ services emerged in the 1960s, with debates about services for the mentally disordered given urgency by a series of hospital scandals,⁵⁸ but the problems had long antecedents. Staffing difficulties, especially endemic recruitment and retention problems, have been seen as a cause and effect of both wartime labour controls⁵⁹ and a series of failed efforts to reform all branches of nursing following the recommendations of the Lancet (1932), Athlone (1937), Horder (1943), Wood (1946), Goddard (1953) and Platt (1964) reports.⁶⁰

The NHS gave increasing attention to manpower planning, but this did little to alleviate nurse shortages or definitively determine staffing requirements.⁶¹ In the mental health and mental handicap sectors problems were arguably more serious, and made worse by the way the special needs and qualities of their staff were often overlooked. American nursing journals had published a number of articles exploring these themes in the 1940s, identifying the successful male psychiatric nurse’s character, leadership skills and insight into nature of self and others.⁶² British research in the 1950s and 1960s concentrated, however, on exploring the alleged immaturity and excessive sensitivities of young women attracted to the idea/ ideal of nursing but repelled by its realities.⁶³ A concern to exclude physically and emotionally frail would-be general nurses did not lead to greater appreciation of the strength and resilience of male mental nurses flagged by other researchers,⁶⁴ but only served to underline differences between the two sectors. Similarly, the career-mindedness and long service of male nurses was noted rather than celebrated in discussions about young women dropping out of training courses. Male nurses were unable to escape the view that their service owed much to economic imperatives and a search for job security despite surveys revealing more men explained their nursing careers in terms of interest in the work and a desire to serve the community.⁶⁵

While the full (and still expanding) mental hospitals and mental deficiency institutions offered some hope of job security for nurses and ancillary staff in the early years of the NHS, a number of threats were emerging. Chatterton (chapter 8) draws an interesting link between efforts to resolve the early NHS staffing crisis in mental hospitals (informed by parallel initiatives across other branches of nursing) and the emergence of a distinctive critique of the asylum as