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The Nightingale Still Sings: Ten Ethical Themes in Early Nursing in the United Kingdom, 1888-1989

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Marsha D. Fowler, PhD, MDiv, MS, RN, FAAN, RSA


There is, by Nightingale’s intent, a centrality of “the moral” within nursing. The good nurse was to be a good woman as well, good in a moral sense. Her writings suggested that the qualities of a good nurse must first be the qualities of a good woman. Early American nursing leaders created an extensive body of literature specifically devoted to nursing ethics that included approximately 100 nursing ethics textbooks and editions. Unlike the American literature, the term “ethics” was rarely used in the United Kingdom (UK) nursing literature and there were few nursing ethics textbooks written by UK nurses. Despite this difference, UK journals and textbooks devoted considerable and ongoing attention to concerns that were specifically ethical in nature. This article describes the design and sources used in an extensive review of the UK literature, and describes ten ethical themes in areas that constitute continuing ethical threads in the first century of UK nursing literature from the 1880s to 1980.

Citation: Fowler, M.D., (April 7, 2021) "The Nightingale Still Sings: Ten Ethical Themes in Early Nursing in the United Kingdom, 1888-1989" OJIN: The Online Journal of Issues in Nursing Vol. 26, No. 2.

DOI: 10.3912/OJIN.Vol26No02PPT722

Key Words: Nursing ethics; virtue; character, profession, calling, ethics history, duties to self, internationalism, suffrage, women, citizenship, civic engagement, patriotism, work conditions, just remuneration, poverty, health disparities, venereal disease, trafficking, child welfare,

We, her descendants who extend her legacy, still hear her inspired voice.Elusive, furtive, with drab brown and buff plumage, the nightingale (Luscinia megarhynchos) is a rather ordinary bird. Until it sings. Its song is rich, powerful, with an extraordinary range and complexity, laden with trills, fluted whistles, creaking, gurgling, rippled notes, and melodic songs. Its song interrupts the night, greets the dawn, warms the day. It is a song worth hearing.

(Nightingale bird singing. Author owns copyright to this video)
The nightingale’s name comes from the Old English nihtgale, meaning night songstress. Perhaps this bird would have been a better symbol for our own Nightingale than the lamp by which she made her own nighttime rounds as she stood guard over her soldier-patients, night and day. She, too, had an astonishing voice, one that ranged broadly and could be heard in nursing, statistics, infographics, social reform, hunger relief, sanitary reform, religion and mysticism, and more. We, her descendants who extend her legacy, still hear her inspired voice. It sings directly and indirectly in the literary, educational, practice—and moral—legacy that she left us. It is a song worth hearing.

Nightingale’s legacy has been that of a profound concern for nursing education that was simultaneously nursing science and practice, and moral formation. Nightingale’s legacy has been that of a profound concern for nursing education that was simultaneously nursing science and practice, and moral formation. She wrote “A woman cannot be a good and intelligent nurse without being a good and intelligent woman” (Nightingale, 1882a, p.1038). There is, in Nightingale’s intent, a centrality of the moral within nursing. The good nurse was to be a good woman as well, good in a moral sense. If moral formation is at the very heart of Nightingale’s vision for nursing education, thereby graduating a morally-formed nursing workforce, how then does that moral emphasis and concern take shape in the subsequent literature of the profession? This article describes the design and sources used in an extensive review of the UK literature. This review identified at least ten ethical strands, discussed within, from the first century of nursing literature from the United Kingdom (UK), between the 1880s and 1980.

Design and Sources

This study entailed a page-by-page physical review and content analysis of the earliest British nursing journals and the earliest UK nursing textbooks and nursing ethics books, dating from the 1880s. The Nursing Record (NR), which becomes the British Journal of Nursing (BJN) in 1902, was published from 1888–1956 and was reviewed in its entirety. The Nursing Times (NT) began publication in 1905 and was reviewed from 1905-1989. In addition, early UK general nursing textbooks, written by nurses, were examined, as the first chapter of these works most often addresses nursing ethics, while the remainder of the book content is clinical. The pre-1965 (when the field of bioethics begins to develop) British nursing-ethics-specific textbooks that still exist, were read in their entirety.

...“ordinary nurses” are represented as well; they, too, wrote articles, opinion pieces, personal experiences, letters to the editor, and more.Quotations within the themes below represent a consensus view within the literature. They represent a specific group of nurses (e.g., educators, matrons, leaders, and writers) who generated the editorials and many of the articles. However, “ordinary nurses” are represented as well; they, too, wrote articles, opinion pieces, personal experiences, letters to the editor, and more.

While considerable attention in all the documents is given to registration, title protection, educational standardization, and such, the themes of concern here are those that are specifically ethical in nature. Content was deemed to be ethical if it principally focused on norms of value, both nonmoral value (goods and ends) and moral value (virtues), and ideals of the profession, or norms of obligation (duties). Nonmoral values are non-person ends, such as health, dignity, respect. Moral values refer to norms such as compassion, courage, patience, and are often referred to as virtues. Content was determined to be social-ethical in nature where it involved a measure of criticism of concepts such as social structures, disparities, injustices, inequalities, and prejudices, based on moral grounds.

The journal and textbook review and analysis indicated several large domains of ethical concern, each sufficiently substantive for its own research. They are given below, in no particular order. There is some overlap of themes, and they may circle back upon one another, or be recombined in other ways. As the nursing ethical literature today does not address the history and development of the British nursing ethical tradition, these ten themes are proposed as a starting point for further research. The themes are more descriptive than analytical in order to provide an initial survey of the ethical content of this period literature and to invite scholars using a variety of critical approaches to additional research.

Ten Ethical Themes in Early Nursing Literature of the UK

Nursing as a Profession, Vocation, Calling, or Trade
...early nursing leaders sought to create nursing as an educated, scientific, profession...Following Nightingale’s vision, early nursing leaders sought to create nursing as an educated, scientific, profession for women working outside domestic service or the home, for which nurses would be paid a just wage commensurate with their education. They also wished to retain a notion of nursing as a calling with the devotion, altruism and other qualities associated with such. It is important to understand that nursing itself was not a calling; a call resides within the individual, and it is the individual who is called to nursing.

The notion of a calling, or vocation (from the Latin, vocare, to call) carried the sense of unpaid service to God, which set up a tension between profession and calling that had to be navigated, and was ultimately preserved as a tension (Nightingale, 1934, p.528). When nursing leaders discovered that they did not have the political muscle to demand “a living wage,” they sought to unionise, which then risked casting nursing as a trade, another facet of this tension (AEM, 1921; Anon, 1919a; Anon, 1920b; Anon, 1919c; dePledge, 1893; Fenwick, 1919; Mollett, 1958).

The literature reflects a desire to honor Nightingale’s intent of nursing as a calling while also embracing nursing as a profession.Early nursing was a balancing act between aspiration to recognition as a profession; the ability to negotiate an adequate and just pay commensurate with education; and skill requiring collective action, while retaining the commitment, character, and ideals inherent to a calling. The literature reflects a desire to honor Nightingale’s intent of nursing as a calling while also embracing nursing as a profession.

This theme also contains a persistent thread on the importance of maintaining ideals in nursing practice and education. This is related to the view of nursing as a profession and, in Nightingale’s words, a “high calling” (MacDonald, 2002, p.74). It emphasizes the importance of ideals, and maintaining and reinforcing those ideals, and their role in practice and teaching (teacher side) and learning (student side). The discussion acknowledges the tension between the ideals espoused by teachers and the profession that then comes into contact with the gritty reality of the nature of nursing practice, and the conditions under which nurses worked. (Anon, 1919a, p. 692; Anon, 1933; Botting, 1919). This tension can be seen as an early precursor to today’s discourse on moral distress.

Character Ethics
...early nursing ethics emphasizes the moral character of the nurseWhile moral duties are discussed, early nursing ethics emphasizes the moral character of the nurse. This was a virtue ethics emphasis, though alternative terms of character, qualities, personality, temperament, and attributes were more commonly used. The term character ethics is more consistent with this literature’s terminology. Nightingale and subsequent nursing leaders and educators were concerned to recruit women of the right character, preferably educated women of the right character (Foley, 1919), and then in the process of nursing education to habituate and develop the essential character qualities (virtues) for a life of practice.

Character ethics was expanded and reinforced through the various relationships that were a part of nursing... This habituation involved classroom education and clinical apprenticeship. Modeling of virtues by experienced nurses occurred in interactions in the practice settings. Character ethics was expanded and reinforced through the various relationships that were a part of nursing, but especially the nurse-to-patient relationship. Within the clinical apprenticeship segment of nursing education, the moral qualities of the classroom teaching were brought to life and enacted within the various nursing relationships.

Nightingale called for nurses to be sober, chaste, honest, truthful, trustworthy, punctual, quiet, cheerful, and cleanly (Nightingale, 1882b). Other moral qualities that were emphasized included patience, compassion, honor, moral courage, and devotion. Moral courage was specifically termed as such (Mollett, 1888, a-f; Mollett, 1889). These were not characteristics that the nurse possessed, like a lavaliere watch, but rather attributes that emerged within the various relationships as occasions arose. It was understood that moral character was essential to the acceptance and guidance of the moral values and ideals of nursing and to right conduct. E. Margaret Fox (1914) elegantly wrote:

In many relationships in life people are inclined to take themselves too seriously; with regard to the profession of nursing you can hardly do so…In no other field of work, save that of medicine, are you brought into a succession of close and delicate intimacies with others. You are admitted where the patient’s nearest and dearest relatives are excluded. You are told what is never breathed even in confidence to wife, mother, or son; your hasty, lightly-expressed opinion may depress or exalt some yearning spirit in a manner out of all proportion to your knowledge or experience.... Is it not, then, important that you should at once begin to realise the responsibilities you have taken upon yourselves in becoming nurses? This sense of responsibility should influence all you say and do, for your words and actions will show what you are.

Therefore, as conduct is the outcome of character, so character is more important in a nurse than mere cleverness. How necessary it is then, that such attributes as reverence, gentleness, discretion, and uprightness should enter into every nurse’s character, and be continually cultivated by the earnest practice of good habits and patient continuance of well-doing (Fox, 1914, p.4).

There is no single, definitive list of virtues to be desired in nurses... There is no single, definitive list of virtues to be desired in nurses, though there are lists, and most lists greatly overlap with one another. They include tact, courtesy, honor, moral courage, devotion (to the patient), loyalty (to one’s school and hospital), selflessness, kindness, punctuality, honor, discipline, and sympathy (Mollett, 1888a-f; Mollett, 1889; Blissett, 1888). However, such lists present two problems that subject them to significant misinterpretation. First, English is a living language; the meanings of words evolve. For example, naughty originally referred to persons who had naught, that is, persons who were poor or needy, not to someone wicked (Oxford English Dictionary [OED], 2020b). In terms of desirable attributes of the nurse, sympathy, in these lists is closer to today’s empathy (OED, 2020a).

A second consideration is that the lists are extracted from the contexts within which they arise and that shape their meaning. For example, consider the characteristics of discipline, obedience, and neatness. Today these words connote subservience, rigidity, and control. However, consistent with the modified military structure of hospitals, discipline and obedience were understood in military terms where one is obedient to superior officers (i.e., not blindly obedient) and also not compliant with unlawful orders. As to neatness, “the nurse must make her personal appearance the subject of extreme care. Every moment of her time on duty she is on dress parade…” (Goodnow, 1916, p.28). Neatness, then, is an element of the quasi-military ethos of the hospital, not some womanly notion of perfection and cleanliness.

The Nursing Times provides an amusing statement of the expected attributes of a morally good nurse:

Recipe for making a good nurse: Mix together equal parts of pluck and good health with well-balanced sympathy, stiffen with energy and soften with the milk of human kindness. Use a first-class training school as a mixer. Add the sweetness of a smile, a little ginger, and generous amounts of tact, humor and unselfishness, with plenty of patience; pour into the mouth of womanhood, time with enthusiasm, finish with a cap and garnish with ambition. The sauce of experience is always an improvement to this recipe, which, if followed closely, should be very successful and exceedingly popular (Anon, 1931, p. 899).

The sequestered education and ethos of nurses resulted in a continued emphasis on character ethics beyond the time society had begun its shift to a duties-based morality. Initially, it looked like the profession of nursing simply caught up in the 1970s and 80s. However, there is a transitional element that helped to propel and facilitate the change. In the later 1950s, nursing schools were experiencing a high rate of “wastage” (i.e., student attrition). To halt the wastage, psychologists conducted studies about nursing students and identified a set of psychological and intellectual attributes that were independent of character and correlated with those who would remain for the full course of education. Nurse educators soon began to employ a range of psychological tests that culled prospective students who did not possess those requisite characteristics. Questions arose about exactly who was choosing new students—psychological tests or nurse educators. This approach appears to have facilitated a transition into the ambient social ethos that placed less emphasis in the profession upon moral character (Clow, 1962; Garside, 1958; Lee, 1960; Revans, 1958).

Discussions about the good nurse were always discussions of the morally good nurse that contained a prior assumption of knowledge, skill, and wisdom, that is, clinical expertise. These character attributes were often linked to the nurse’s duties to self; indeed, Fox’s ethics chapter is titled “The Ethics of Nursing and the Care of the Nurse’s Own Health” (Fox, 1914, p. ix).

Duties to Self
Throughout the early nursing literature nurses were enjoined, even commanded, to care for themselves. Duties to self, as it was termed, was a broad-reaching, aggregate duty that included maintaining and promoting one’s own physical, mental and spiritual wellbeing. Specifically, it included the basics of sleep, nutrition, keeping warm, exercise, recreation, and ongoing learning.

Recommendations in this domain were extensive and addressed every aspect of the nurse’s life. Recommendations in this domain were extensive and addressed every aspect of the nurse’s life. They appear in multiple articles, columns, and standing sections in every issue of the journals reviewed. Entire articles were devoted to recommendations for reading for pleasure and for learning. Columns are devoted to reading recommendations for both medical and nursing books, as well as health books for persons who might need nursing attention (e.g., mothercraft books). Articles and columns covered such broad topics as economical ways to travel and inexpensive destinations for holidays; instructions for how to go camping; a 12 part series on table tennis; patterns for sewing and knitting; recipes for all occasions; recommendations for how to make a home in one’s rented lodgings; how to engage in birdwatching from the hospital windows; local wildflowers in bloom; information about a range of sciences such as geology; astronomy; how to write poetry; how to act in a drama or skit; how to speak in public; recommendations for spiritual development; and much more. Suggestions were given for plays to see, museums and exhibits to visit, and places to go trekking. This was not simply for the nurse’s wellbeing, but for her enjoyment of life and understanding of the natural world around her. Journals sponsored multiple competitions, including lawn tennis, table tennis, essays on a range of nursing and non-nursing topics, first person stories, and many others.

An extraordinary amount of journal space in every issue is given to fostering the wellbeing of the nurse, for the nurse’s own sake. An extraordinary amount of journal space in every issue is given to fostering the wellbeing of the nurse, for the nurse’s own sake. It was recognized that a nurse’s health and wellbeing also benefit the patient and employer, but the emphasis of this literature was upon the nurse, for the nurse’s own sake. This literature promoted a very broad, liberal, education; world awareness, political awareness, and knowledge of the physical world; well spent leisure and recreation; broad reading; ongoing learning about the natural and social world around the nurse; ongoing learning in nursing; maintaining sound friendships and social relations within nursing; the health of the nurse, including rest, recreation, nutrition, hygiene, and foot care; going to plays and concerts; clothing, travel, hobbies and sports; financial, housing, and legal advice; and much more. This is an extensive, resolutely positive, helpful, and charming literature that cares for the nurse as a whole person.

Internationalism and the Social Location of Women
This theme calls all nurses to have an interest in nursing worldwide. The profession of nursing began with an internationalist impetus. Nightingale herself catalyzed nursing through her work in the Crimea, subsequently pursued sanitary reform for India, traveled to Egypt, and more. This theme calls all nurses to have an interest in nursing worldwide. It aligns with concerns for the social location of women which is seen as determinative of any possibility of the progress of nursing. Minnie Goodnow (1938) wrote in separate passages:

The nurse should be able to trace the fact that her profession is a part of the whole “woman” movement, of the struggle of women down through the ages to free themselves from the domination of men and to take their places in the world as individuals, with the liberty and responsibility which that involves. The progress of nursing has gone hand in hand with this struggle; and it is in the countries where women are freest to live their own lives that it has made its greatest successes. It is important also, in these days when all questions are becoming international ones, that nurses should know what is taking place on the other side of the world (Goodnow, 1938, p. 18).

The woman movement is not yet complete...there are enormous numbers of women still untouched by it. It involves problems of early marriage versus late—which usually means education or lack of it; and of marriage versus career, a still more fundamental question. Another huge world-problem is nationalism versus responsibility for other nations...shall we, can we live in splendid isolation and develop ourselves and our own country? Or must we perforce accept the responsibility of seeing that the countries of the world progress more or less together? Nurses...easily see their duty to community, to their nation. Can they, through education through travel, through contacts of any sort, come to see their duty to other nations? Nursing history answers that they have. For many years they have gone out to the ends of the earth to help other countries develop good nursing…. the world lies before nurses…shall we prepare for the challenge of humanity and then go to its help? (Goodnow, 1938, pp. 311-12).

At the very least foreign travel and reading were encouraged.While nurses are prodded to international engagement, there were varying levels at which this was expected. At the very least foreign travel and reading were encouraged. While some of that travel was for holiday purposes, it was often a “busman’s holiday” that entailed visits to hospitals, nursing schools, and nurses in other countries. There are first-person articles from nurses reporting on hospitals or nursing in Europe, South America, Africa, North America, and some countries that no longer exist.

Nurses could see evidence of international collaboration through the reports of various leaders, and had the opportunity to participate in the international nursing congresses of the International Council of Nurses (ICN), founded in 1899. The International Nursing Review journal (INR) was started in 1953 but followed less formal predecessor publications (ICN Calling; International Nursing Bulletin). The journal, along with ICN international congresses and publications, helped to coalesce the international nursing community. The ICN remains the largest organization of women in the world (though not exclusively comprised of women today).

Citizenship, Civic Participation, Political Engagement
Nursing ethics and early nursing history textbooks gave considerable attention to the nurse-as-citizen theme, as did professional associations. For example, the 1909 ICN congress divided its sessions as follows (BJN, 1909):

  1. The International Standard of Nursing Education
  2. The Nurse in Private Practice
  3. The Nurse as Citizen
  4. Morality in Relation to Health
  5. The Care of the Insane
  6. The Nurse as Patriot
  7. The Nurse in the Mission Field
  8. The Relations of Nursing to Medicine

At the turn of the century nurse leaders were dedicated to the suffrage movement. Some nurses were arrested, brutally beaten, force fed, and some died for their participation in protests. Some of the horrors of the movement were depicted in the 2015 centennial film, Suffragette (Gavron, 2015). Nurse leaders who struggled for women’s rights, in part so that they could create a profession for women, enjoined all early trained nurses to vote, be informed voters, follow the machinations of Parliament, support any nurse who would stand for MP, and to perhaps become that nurse-MP (Breay, 1937; Fowler, 2020; Kent, 1919).

Every issue of these journals reported on Parliament about women’s suffrage, the Poor Law, midwifery, nursing, children, factories, and all things that touched upon health. The journals also printed various reports or minutes of sessions of Parliament. These leaders and educators had no truck with nurses who were not politically informed.

Patriotism, Heroism, and Edith Cavell
Throughout early nursing literature, nurses were called to be patriotic. Patriotism was used as a general notion for any concerted service to the country.

This is patriotism as we reckon it: that, come weal or woe, come peace or strife, in the training school as on the field of battle, in hospital work, in the district, in the home of the rich as in the one-roomed tenement, in the factory, in the prison, in the workhouse, in the mission-field, we are banded together at all times, and with all our powers of mind and body, not merely to succour the sick in body and the diseased in mind and spirit; beyond and above all that, to undermine the conditions which lie at the root of disease (Broderick, 1909a, p. 116).

District nursing, workhouse or Poor Law nursing, and tenement nursing were regarded as patriotic forms of nursing service that focused both on those in need of nursing care as well as on the conditions that lay “at the root of disease” (i.e., the social determinants of illness and health).

With the advent of WWI and WWII, patriotism becomes linked to wartime service and to heroism... With the advent of WWI and WWII, patriotism becomes linked to wartime service and to heroism, particularly following the execution of nurse Edith Cavell. Cavell was a British nurse and director working in Belgium who helped save the lives of both German and Allied soldiers, and helped British, French, and Belgian soldiers and German draft-aged males escape German-occupied Belgium. She was betrayed, tried by court-martial, convicted of war treason, and sentenced to death. There were worldwide news coverage and pleas for clemency. She was executed by a German firing squad, 12 October, 1915. Her execution was condemned internationally (Anon, 1917).

Nurse Edith Cavell’s body was repatriated in May of 1919 in a solemn national event. Her execution also became a part of the war propaganda machine. That notwithstanding, she became a symbol of nursing patriotism, humanitarianism, and heroism in Britain and among nurses around the world. She was placed on the calendar of saints (October 12) by the Church of England (Anon, 1917; Anon, 1919e, Church of England, n.d.).

The day before her execution Cavell wrote a tender letter to the nurses of her training school and hospital in which she prays their forgiveness for any error, severity, or grievance they might have against her. She bids them farewell with a call to loyalty to one another and an esprit de corps (Anon, 1917).

Nurse Pay, Just Remuneration, Work Conditions, Overstrain, Equity
It is extremely difficult to find a single journal issue that does not contain some material...about the inadequacy of remuneration, the exploitation of nurses, deplorable work conditions, or nurse overstrainIt is extremely difficult to find a single journal issue that does not contain some material, whether an editorial, article, letter to the editor, or even a poem, about the inadequacy of remuneration, the exploitation of nurses, deplorable work conditions, or nurse overstrain (Anon, 1889; Fenwick, 1888b). When nursing wages were compared with scullery maids and porters, nurses did not fare well with what was called their “charwoman pay.” Given the extent of the nurses’ formal education, both classroom and apprenticeship aspects, nurses were greatly underpaid, not just among educated professions, but even among women’s occupational groups. The nature and hours of the work were difficult, but conditions of the work setting could be difficult to deplorable.

Nurses were required to “live-in” (as were students) and their living quarters could be inadequately furnished, shared with many, unheated, and the food inadequate in amount and nutrition. With a customary work schedule, nurses suffered fatigue and illnesses. However, where pressed farther, nurses suffered over-fatigue— a kind of fatigue from which one does not easily bounce back, and overstrain which referred to an excess of both physical and emotional stress. Overwork was pervasive in the nursing world.

British nursing journals also documented reports of overworked nurses in other countries: “Nursing problems are the same the world over. The old question of nursing overwork is now being discussed in the Dutch nursing world…. Some are literally “worked-out” after a few years” (Anon, 1911a, p. 21). Overstrain is so pervasive that in 1912, H. Hecker, of Germany, delivered an address to the ICN on “Overstrain of Nurses” (Hecker, 1913, p. 27; Anon, 1913; Anon, 1919d).

Poverty, Class, Health Disparities, and Access to Nursing
The primary concern was for access to care, but this inevitably raised the issue of cost of care. This literature expresses a persisting concern for the middle class and their access to nursing care and midwifery. The primary concern was for access to care, but this inevitably raised the issue of cost of care. An editorial called for “the provision of hospital accommodation for that large class of the community too well off to be properly admitted into the wards of voluntary hospitals and too poor to be able to afford private nursing home fees…” (Anon, 1909, p. 397). The concern for access to care was attended by the concern for the cost of care and that the allocation of hospital beds for middle class patients was inadequate. Nurses were intimately aware of the health price of poverty:

We know all too well the difficulty of treating cases of serious illness and complicated surgery in the small private house [the patient’s home], and from personal knowledge can supply a mental picture of the inevitable confusion in such homes, often maintained on tiny incomes, allowing of hardly any margin for emergencies of this nature, when father or mother is suddenly struck down by disease or accident; the want of adequate accommodation, the absence of all conditions that must be assured if the patient is to be nursed back to health; and even if, at untold trouble, these are more or less secured, the grinding anxiety attendant upon the weekly addition of expenses which will cripple the family resources for many months to come (Broderick, 1909a, p. 116).

Venereal Disease. Though articles were titled with the words “venereal disease” (VD) those titles were simply the vehicle to address much broader and pressing concerns for women in general, and poor women specifically, including prostitutes, girl-children trafficked for sex, unmarried mothers, and sexual assault on young girls. VD was chosen as the theme designator as it was used as a veneer under which these deeper concerns for women were addressed. For example, Lavinia Dock’s book, Hygiene and Morality (1910), ostensibly about VD, had a single, competent, 52-page, first chapter on the microbiological and clinical signs, symptoms, and progress of various venereal diseases. This was followed by 112 pages of trenchant and excoriating social analysis. She condemned Parliament and the British legal, judicial, and political system, all of which unjustly ensnare women. She tackled issues of women forced or sold into prostitution; of limited, short-term survival prostitution (for family economic survival); of police who sexually abuse prostitutes who have been incarcerated; of judges who punish prostitutes but not the men; of legislators who deliberately design laws that will punish the women without actually ending prostitution; and a chapter on “the white slave traffic,” i.e., girl-child trafficking for sex. She noted that legislators provided the legal hedge of a misdemeanor that permitted the abduction of propertyless girls under age 16 for “immoral purposes” (Dock, 1910, p107). As to the prevention of syphilis, gonorrhea, and chancroid, Dock sarcastically noted that “the [male] generative organs do not suffer from non-use” (Dock, 1910, p. 135).

Girl-child trafficking for sex received significant attention in this literature... Girl-child trafficking for sex received significant attention in this literature, beyond that of Dock’s landmark work (ICN, 1909). Mary Burr conducted a statistical analysis of the incidence of sexual assault on young girls which was published in 1909 (Burr, 1909). Dock, Burr, Broderick, and others supported their positions and actions with hard data, demographic and statistical research, and analysis.

Both the Nursing Times and the Nursing Record ran articles on the clinical aspects of VD. Both also ran articles that pointed out the injustices of the socio-medical approach to managing VD. Here, as elsewhere, British and American nurses were united. In 1911, the British Journal of Nursing weighed in on the proposed Page Bill in New York:

The women, including the trained nurses in America, are conducting their campaign against the obnoxious clause 79 of the Page Bill in New York, by taking the unassailable position that it is not only monstrous but unscientific to compulsorily detain and treat the persons of one sex who have contracted a contagious and communicable disease, and to hope by this means to eradicate the disease, while no control is exercised over the members of the opposite sex, by whom it is originally communicated to the woman compulsorily incarcerated (Anon, 1911b, p. 233).

In the conclusion of her speech on VD at the congress of the 1909 ICN, Albinia Broderick issued this exuberant call to nurses for action:

Form square and stand shoulder to shoulder, nation to nation, fighting for the human race, fighting for our national reputation, fighting for the good name of our century, fighting for the God-given right of health. For innocent women and children, fighting not against, but on behalf of, our poor sisters the prostitutes, she suffers from our culpable neglect and ignorance, fighting dear sister-women as which of us has not fought in our day, for the body and soul of the guilty, because his redemption is possible. So, let us stand steadfast, unfearing. We dare not fail. Nay, we cannot fail. For the weapons of our warfare are Knowledge, Unity, and Love unbounded; the legend on our banner is Light, and the aim of our strife is Peace. Hail comrades, and God speed to victory (Broderick, 1909b, p.173).

Concern for women, even for female prostitutes whom society stigmatises, and in the face of their legal and social persecution, is unrestrainedly declared.

Waif, Foundling, Bastard, Child Health, and Welfare
Very early on, nursing diversified into approximately 20 different specialties, two of which were pediatric and district nursing. District nurses (visiting nurses in the United States), would see patients in their homes — and children in the streets, foundlings abandoned on doorsteps, children of one or both alcoholic parents, children of unemployed fathers, children laboring in factories, children born out of wedlock, and girl-children pregnant from rape. The nursing journals followed the deliberations of Parliament and its legislation, and the journals had a lot to say about the inadequacies of the legislation and the consequent child suffering that nurses witnessed. Much of the infant-related material was offered in the midwifery journal pages, published as a section within the larger nursing journals. Attention was given to the actual care of these children, as well as legislation that affected their welfare and well-being. There was particular concern for unwed, pregnant girls or young women and their children who fell under the bastardy laws.

Attention was given to the actual care of these children, as well as legislation that affected their welfare and well-being. The Ancient Statute of Merton (1235) considered to be England’s first statute, defined legitimacy: "He is a bastard that is born before the marriage of his parents” (Great Britain, 1963, p. 192). The Poor Law of 1576 subsequently became the basis of law regarding illegitimate children. The intent and purpose of the law was to punish the infant’s parents and “to relieve the parish of the cost of supporting the mother and child” (MacFarlane, 2002, p. 71). If the father were known, he could be pressured to pay upkeep. In reality, the law primarily punished the mother and child, often leaving them destitute and stigmatised for life. The Nursing Times called for “greater care of the illegitimate child” and supports the revision of the bastardy laws to require the father’s financial support for the pregnancy and for sustaining the child and mother after the birth (Anon, 1920a, p. 488).


Many of the issues that these ten themes address have persisted from the start of modern nursing for well over 150 years, and have been refractory to resolution. Their ultimate resolution lies, as early nurse leaders insisted, in the united voice and action of nurses worldwide – and in nurses’ participation in social and health policy reform. If nurses had the strength of will and unity, coming together as one strong voice on these issues, then laws, social attitudes, and cultures could not withstand its irresistible force. According to the 2019 WHO World Health Statistics Report, there are approximately 20.7 million nurses and midwives in the world (WHO, 2021). That could be strength enough to move any nation.

It would be difficult to examine these themes and not agree that the profession of nursing’s ethical tradition is...the bedrock of nursing’s identity... Some of these ten themes are discrete but others have fuzzier boundaries and can merge. For example, the concern for children, and for illegitimate children in particular, overlaps with that for the young unmarried mother and the VD theme. There is no claim that this list of themes is a definitive or exhaustive typology. The attempt here is to describe themes that emerged from this research, to hint at the persistence of most of these concerns that extends to the present (and is not limited to the UK), and to invite scholars to become immersed in the ethical riches of this essentially untouched body of literature. It would be difficult to examine these themes and not agree that the profession of nursing’s ethical tradition is, as Nightingale intended, the bedrock of nursing’s identity and is the core of pride of our profession. Broderick synthesizes these themes when she speaks of concern by nurses for the whole of humanity. Listen to Albinia’s words:

The wakening of our profession throughout the civilized world to a deep sense of what each of us owe individually, not merely to our patient, to our hospital, or to our guild, not even to our country itself, but rather to the whole of humanity, is proceeding coevally with the wise and much needed development of training methods and of scientific knowledge, and the cultivation of a high professional ideal amongst us (Broderick, 1909a, p. 116).

Nightingale, and the early nurse leaders who followed her, was adamant that nursing, as an educated, scientific, profession, and calling for women had something pivotal —and peace promoting—to offer to healthcare, to the needs of the British people, and to the needs of the humanity. She was correct, as are those who take up her song today.

Acknowledgement: Fulbright Research Grant, Award #83349


Marsha D. Fowler, PhD, MDiv, MS, RN, FAAN, RSA

Dr. Fowler holds a PhD in Social Ethics and has researched the history and development of US nursing ethics for 40 years. She held a Joseph P. Kennedy Jr. Fellowship n Medical Ethics at Harvard University, and is the recipient of the ANA Honorary Human Rights Award. She recently completed a Fulbright Research Award to research the history and development of nursing ethics in the UK. Dr. Fowler has served the ANA as

  • Committee on Ethics, member, 1985-87
  • Chairwoman, Committee on Ethics, 1987-89
  • Consultant to the task force, for revision of the 1984 Code for Nurses
  • Project team, evaluation for revision of the Code for Nurses, 1995
  • Member, task force for the Revision of the Code for Nurses with Interpretive Statements, 1996--2001
  • Member, Task Force for the Review of the Code of Ethics, 2012-2013.
  • Member, Steering Committee for the revision of the Code of Ethics for Nursing with Interpretive Statements; designated committee Historian and Code Scholar, 2013-2014

She has published extensively in the field of ethics, focusing on the history and development of nursing ethics. Dr. Fowler is currently serving on the writing subgroup for the revision of the code of ethics of the International Council of Nurses, 2019-2020.


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© 2021 OJIN: The Online Journal of Issues in Nursing
Article published April 7, 2021

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