Nurse Education Today 35 (2015) 635–637

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Big Ideas Why history matters to nursing

The history of nursing is rich and complex; and yet for most people including many nurses it is a sparsely populated narrative. Commonly known historical facts are limited to events marking the progress to greater professional status such as the establishment of training schools and the introduction of registration, enlivened by the stories of a few heroic individuals, Florence Nightingale being the most notable. Popular understanding of nursing history is often drawn from films, autobiographies, novels and television programmes featuring the roles nurses played in both world wars and the development of modern healthcare systems. For many nurses this lack of knowledge is of little concern. The relative paucity of nursing history publications suggests a prevailing view that history has minimal relevance to twenty first century health care delivery or related academic practice. However, this paper will argue that history has much to offer nursing and indeed is essential to fully appreciate the contemporary debate about the state of nursing particularly in the UK. It will also show how the inclusion of history in nursing curricula could contribute to a more complete sense of professional identity and help develop critical thinking skills that are very relevant to the complex and uncertain situations faced in contemporary nursing practice. The social utility of history has been contested by historians and others and continues to be debated (Cannadine, 2001; Carr, 1987; Elton, 1967). Tosh (2008) explains that the pure accumulation of historical knowledge, ‘history for its own sake’ developed from the nineteenth century onwards as part of the process of professionalising history as an academic discipline. The misuse of history to support totalitarian regimes as witnessed in Nazi Germany and Stalinist USSR arguably led to greater reluctance by historians to promote the value of history in the wider public arena. By the 1990s post modernist thinking was challenging not only the purpose of history but also its very existence as a legitimate scholarly pursuit (Evans, 1997). Yet, from these challenges has emerged not only a robust defence of history as a discipline, but a growing interest in exploring the contribution history can make to contemporary society (Jordanova, 2008). The arguments constructed and revisited by historians as part of this process, particularly those presented by John Tosh (2008) in his book ‘Why History Matters’ have clear relevance to nursing. In the twenty first century history appears to be thriving as demonstrated by the proliferation of history and heritage related books, entertainment and leisure activities. Yet, historians believe that there is limited critical historical awareness in the public domain. This could be attributed to failures in the education system. Indeed, the longstanding debates about the school history curriculum in the UK indicate there is little agreement about the content and purpose of history taught at this level (Mansell, 2013; Evans, 2013). But it is also the prevalence and presentation of popular history that is an issue. Tosh (2008) highlights the contribution of ‘heritage’ to the lack of awareness arguing that it ‘displaces historical consciousness’ (p11). Instead, he suggests,

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it offers a distorted perception of the past, simplified, sanitised and focused on material objects which invite people to see similarities between their lives and those in the past, obscuring the profound differences in terms of social values, cultures and mentalities. Tosh (2008) argues that this lack of critical awareness impacts on civic and democratic functions, including politicians, policy makers and the media as well as ordinary citizens in this analysis. Reflecting similar concerns Jordanova (2000) argues, that a role of the historian therefore is to develop forms of history for the public that are ‘critical and self-aware as well as fun’ (p.21). This lack of historical awareness can be illustrated by the case of nursing in the UK. Recent years have seen nurses vilified in the press following a series of critical publications culminating in the high profile Report of the Mid-Staffordshire NHS Foundation Trust Public Inquiry (Francis, 2013). Much of this media critique has compared nursing today with that in the past, inferring a ‘golden age’ of nursing characterised by a caring, compassionate workforce, lacking ambition in terms of occupational status and academic aspirations. This contrasts with the belief held by many in the profession that the history of nursing is an upward trajectory of progression linked to better education, higher professional status and more technical and specialised roles. The conflation of these ideas has led to a dangerously simplistic analysis that the perceived current poor state of nursing is linked to the improved educational standards, typified by the newspaper epithet ‘too posh to wash’. As Gillett (2014) notes in her critical discourse analysis of nostalgic representations of nursing education in British newspapers, many of the observations are based on the memories of those who were nurses or were nursed in previous decades. This autobiographical element perhaps intuitively supports the validity of these commentaries for readers but as Gillett points out memories are often used to construct ‘positive self representations’ and group identities. This process is often unconscious and a universal human trait is the lack of insight into this process and not to recognise the gaps and distortions in our own memories. For these reasons historians have always showed caution in utilising memories particularly those of several decades ago as sources in their research (Jordanova, 2006; Tosh, 2010). The myth of a golden age of nursing is also supported by a romanticised portrayal of nurses in the popular history of films, television programmes and written fiction. Although, often created with a factual historical basis the need for compelling dramatisation and comfortable consumption may outweigh any compunction to stick closely to the facts (Cannadine, 2002). The truth is that we do not know whether nurses were more caring and compassionate in previous decades. However, history does show us that there have been previous concerns about the quality of care in many settings throughout the history of the National Health Service (Robb, 1967; NHS, 1969, 1972). Although nursing history is developing as a discipline it remains under researched and has mostly focused on key events and processes linked to professionalisation rather than nursing practice. What we do know is that complex and ephemeral concepts such as care and compassion have been expressed, experienced and communicated in

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Big Ideas

different ways over time. For example, Van der Cingel (2014) argues that compassion became linked with vocational self sacrifice in the late nineteenth and early twentieth centuries as aspiring professional nurses sought to differentiate themselves from poorly paid, untrained workers and thus ‘contaminated’ it as a value for nursing. Tosh (2008) suggests that the creation of powerful myths can be a consequence of lacunae in historical knowledge. Certainly, in the case of nursing the absence of accurate historical knowledge has made the golden age of nursing myth hard to contest. The lack of historical critical awareness has meant that it has been accepted as true by many within nursing and beyond. This is of concern because it potentially affects public trust in today's nurses to provide high quality, safe care and the decisions of politicians and policy makers. The reduction in public trust could negatively influence the wellbeing and health outcomes of those receiving care and the ability of nurses to deliver that care. Public concern about nursing as expressed by the media and patient groups has added weight to the need for clear policy solutions from Government in response to the Francis Inquiry Report. This has led to a series of policy actions such as the Compassion in Practice strategy spearheaded by the Chief Nursing Officer for England (www.england.nhs.uk/nursingvision/) and a range of recommendations relating to nurse education (Willis, 2012; Francis, 2013). These may be laudable and indeed ultimately effective but if motivated or influenced by an inaccurate representation of nursing's past then potentially fundamentally flawed. If the underlying assumption is that nurses were more compassionate in the past, then policy solutions may be based on simplistic attempts to recreate conditions in which this can happen again. This is manifested in policy focused on changing the behaviour of nurses, through their pre-registration education and prescribing their practice; for example selection processes for pre-registration education and intentional rounding. This does not mean that the government necessarily believe that nurses were more compassionate in the past or that poor care is linked to better educational standards, but the power of the media portrayal is such that without a credible rebuttal they have to be seen to respond to the problem as framed by this public discourse. Berridge (2007) found that UK health policy makers never formally utilised history or historians, as they wanted to be seen as innovative and forward thinking. However, in this case, history could provide insights that would help frame the situation more accurately, and provide a counter weight to the powerful, negative media construction of the problem. Research in the history of nursing and midwifery is expanding and becoming more sophisticated (Borsay and Hunter, 2012; Mortimer, 2005). However, there are many areas left unexplored, greater knowledge of which could usefully inform the present. For example a better understanding of how caring and compassion were conceptualised, delivered and experienced by nurses and patients in the past would reveal a more complex reality than that suggested by the golden age myth. It would certainly highlight how profoundly and irrevocably different the context of health care delivery was fifty years ago thus undermining simplistic comparisons between nursing in the present and that in the past. In this way it could complement and support recent studies that indicate that the environment in which nurses work, including staff/ patient ratios, influences their capacity to provide safe and compassionate care (Maben et al., 2007; Ball et al., 2014; Aiken et al., 2014). The absence of critical thinking in relation to nursing's past is at odds with the approach to evidence that nurses are expected to take in their practice. Indeed, the development of critical thinking skills is cited as a reason for including history in nursing curricula (Lewenson, 2004; Madsen, 2008). Lewenson and Madsen outline the challenges in delivering history content that is interesting, engaging and enables students to see the relevance for current practice. As well as critically reviewing existing historical research it is important to explore what is not known and how the absence of research based knowledge about our past can influence our professional identity.

Lewenson (2004) and Madsen (2008) both highlight how history can contribute to a greater sense of identity for nursing students by enabling them to see how the past has shaped the present. Tosh (2008) recognises and welcomes the contribution of identity history but cautions against the development of one-dimensional linear histories that with the aim of affirmation for the group in question, ignore social, moral and cultural complexities. Accurate representations of nursing history reveal elements that may be repellent to the values and beliefs of today. For example, we may find the involvement of early twentieth century nurses in suffragist campaigns admirable but less so their support for the eugenics movement. An important skill for historians is to see the past from the viewpoint of that time and not with the benefit of hindsight or with knowledge and values of the present. Nelson and Gordon (2004) propose a ‘rhetoric of rupture’ in which in an attempt to achieve social legitimacy, nursing constantly disowns and disparages its past, particularly in relation to skills and practice. They contrast this with the history of the medical profession continuously evolving in the light of developing scientific knowledge, and yet accepting the value and contribution of earlier medical practice and practitioners even that which we now know to be ineffective, unethical and unsafe. A strong, confident sense of identity and accurate historical awareness would enable nurses to embrace the complexity and differences of nursing in the past not judging them in the light of current knowledge and values. Increased understanding of how nursing has continuously changed and developed in response to social, political, economic and cultural pressures from within the profession and without would allow current challenges to be viewed as part of this ongoing process of adaptation. A knowledgeable and critical understanding of the past would lead to the discernment needed to draw valuable lessons from past practice and discard those with little value to nursing today. To achieve this nursing history must develop as an academic discipline to provide the rich description and critical interpretation of past nursing practice needed to fill the gaps in our understanding. This growing historical knowledge and the skills to think critically about the past would enhance the academic development of nursing students, strengthen their shared identity as nurses and their ability to contribute effectively to the ongoing challenges of providing the health care that the present and future expect. References Aiken, L.H., Sloane, D.M., Bryneel, L., Van den Heede, K., Griffiths, P., Busse, R., Diomidous, M., Kinnunen, J., Kózka, M., Lesaffre, E., McHugh, M.D., Moreno-Casbas, M.T., Rafferty, A., Schwendimann, R., Scott, P.A., Tishelman, C., Van Achterberg, T., Sermeus, W., 2014. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 383 (9931), 1824–1830. Ball, J.E., Murrells, T., Rafferty, A.M., Morrells, E., Griffiths, P., 2014. ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Qual. Saf. 23, 116–125. Berridge, V., 2007. History Matters? History's Role in Health Policy Making. History & Policy, London. Borsay, A., Hunter, B., 2012. Nursing and Midwifery in Britain since 1700. (Eds). Palgrave Macmillan, Basingstoke. Cannadine, D. (Ed.), 2002. What is History Now?Basingstoke, Palgrave Macmillan Carr, E.H., 1987. What is History?. 2nd ed. Penguin Books, London Elton, G.R., 1967. The Practice of History. Sydney University Press, Sydney. Evans, R.J., 1997. In Defence of History. Granta Books, London. Evans, R.J., 2013. Michael Gove in History Wars (The Guardian Sat 13th July 2013). Francis, R., 2013. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The Stationery Office, London. Gillett, K., 2014. Nostalgic constructions of nurse education in British national newspapers. J. Adv. Nurs. 70 (11), 2495–2505. http://dx.doi.org/10.1111/jan.12443. Jordanova, L., 2000. Public History. History Today 50 (5), 20–21. Jordanova, L., 2006. History in Practice. 2nd ed. Arnold Hodder, London. Jordanova, L., 2008. How History Matters Now. http://www.historyandpolicy.org/papers/ policy-paper-80.html (accessed 17/12/14). Lewenson, S.B., 2004. Integrating nursing history into the curriculum. J. Prof. Nurs. 20 (6), 374–380. Maben, J., Latter, S., Macleod Clark, J., 2007. The sustainability of ideals, values and the nursing mandate: evidence from a longitudinal qualitative study. Nurs. Inq. 14 (2), 99–113.

Big Ideas Madsen, W., 2008. Teaching history to nurses. Will this make me a better nurse? Nurse Educ. Today 28, 524–529. http://dx.doi.org/10.1016/j.neddt.2007.09.008. Mansell, W., 2013. Michael Gove redrafts new history curriculum after outcry (The Guardian Friday 21st June 2013). Mortimer, B., 2005. The history of nursing: yesterday, today and tomorrow. In: McGann, S. (Ed.), Mortimer B. New Directions in the History of Nursing, Routledge, London. National Health Service, 1969. Report of the Committee of Inquiry into the allegations of ill treatment of patients and other irregularities at the Ely Hospital, Cardiff. Cmnd 3175. HMSO, London. National Health Service, 1972. Report on Whittingham Hospital. Cmnd 4861. HMSO, London. Nelson, S., Gordon, S., 2004. The rhetoric of rupture: nursing as a practice with a history? Nurs. Outlook 52 (5), 255–261. Robb B. & Association for the Elderly in Government Institutions, 1968. Sans Everything: A Case to Answer. Nelson, Michigan.

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Tosh, J., 2008. Why History Matters. Palgrave Macmillan, Basingstoke. Tosh, J., 2010. The Pursuit of history. 5th ed. Routledge, London. Van der Cingel, M., 2014. Compassion. The missing link in quality of care. Nurse Educ. Today 34, 1253–1257. http://dx.doi.org/10.1016/jnedt.2014.04.003. Willis Commission on Nurse Education, 2012. Quality with compassion: the future of nurse education. Report of the Willis Commission 2012. Royal College of Nursing, London.

Annie Holme King's College London, Florence Nightingale Faculty of Nursing & Midwifery, United Kingdom

Why history matters to nursing.

This paper proposes that poor knowledge and understanding of the history of nursing particularly in the UK influences the media and public analysis of...
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