International Journal of Nursing Practice 2001; 7: 169–176

LIVING IN POVERTYIn the nineteenth century, Britain emerged from a pre-dominantly rural society to become an industrial societythat expanded its boundaries to influence and shape thehistory of many other cultures in the world.1 The peacethat Britain and her dominions experienced following theNapoleonic wars facilitated a period of prosperity, growthand expansion. Britain became a sovereign nation, extend-ing her influence throughout the far corners of the globe.However, prosperity did not reach all levels of society.1

Industrialization, growth and expansion of the economy

following the Napoleonic Wars came at a price for somewithin British society. Many rural and cottage industryworkers were displaced by the modernization of industry,improvements in agricultural practices, increasing non-profitability of farming on a small scale, and the closureof common lands by the State, which resulted in the lossof traditional incomes and ways of life.1 For many people,poverty became a way of life, although McCord cautionsthat living in poverty was not a new experience but anage-old problem.1

PHILANTHROPY:THE TRADITIONALROLE OF THE CHURCH

Traditionally in the UK, the poor and infirm had beencared for by religious people from the Roman Catholic

✠ R E S E A R C H P A P E R ✠

Service to the poor:The foundations of

community nursing in England, Ireland and

New South Wales

Karen Francis BHlthSci(Nsg), MhlthSci, PhDUniversity of Adelaide, Adelaide, South Australia, Australia

Accepted for publication August 1999

Francis K. International Journal of Nursing Practice 2001; 7: 169–176Service to the poor:The foundations of community nursing in England, Ireland and New South Wales

This paper describes the foundations of community nursing in England, Ireland and New South Wales. It is guided by Foucault’s work on power, discourse and knowledge, and argues that the common discourse of poverty coupled with theinfluence of socially advantaged women in the nineteenth century was the impetus for the development of communitynursing in England, Ireland and New South Wales. Throughout the nineteenth century in Great Britain, economic andindustrial development, coupled with an unprecedented growth in the population (particularly among the poor) inspiredsocially advantaged women to extend traditional gender-specific roles to address the needs of the poor. Protestant womenin England advanced professional nursing as a career for women and in Ireland and New South Wales; Catholic womenpioneered professional nursing, targeting the poor as the focus of their practice.These women used prevailing social con-ditions to enhance their life options within the limits prescribed by social norms.

Key words: Catholicism, community nursing, England, Ireland, New South Wales, poverty, Protestantism.

Correspondence: Karen Francis, School of Health and Human Services,

Charles Sturt University, PO Box 588,Wagga Wagga 2658, New South

Wales, Australia. Email: kfrancis@csu.edu.au

170 K. Francis

Church.2 The sick were cared for within the monasteriesand nunneries by religious men and women, or werevisited in their homes by the religious and also by womenof the gentry as tradition decreed.2 Visitation of the sickallowed religious people access to homes, and was a strat-egy of surveillance to monitor the behaviours of the congregation.3 Following the dissolution of the RomanCatholic monasteries during the reign of Henry VIII, pro-vision for the poor and infirm was neglected.2

. . . the injury inflicted upon the whole system of Catholic chari-

ties by the upheaval of the sixteenth century was disastrous in many

ways to the work of the Hospitals.The dissolution of the monaster-

ies, especially in England, deprived the Church, in large measure,

of the means to support the sick and of the organisation through

which those means had been employed (Walsh; stated in Murphy,p. 2).4

The closure of the monasteries, the cessation of socialwelfare and the subsequent rise in pauperism led Eliza-beth I to legislate the Poor Laws. Under the Poor Laws, assis-tance was provided in two forms: (i) outdoor relief, whererecipients were provided with money, food and medicalcare in their homes; and (ii) indoor relief. Indoor reliefrequired recipients to be placed in an abode set aside for the impoverished. The Protestant Church of England saw philanthropy or charitable activity as a religious duty.2

However, the poor were viewed with suspicion by thewider society, which encouraged industry and productionnot idleness.1

Foucault explanation is that society adopts beliefsystems that function as forms of power by subjectifyingindividuals as objects. Subjectification implies that a powerrelationship exists, which Foucault argues is relational to knowledge. Knowledge and power, he claims, serve toauthorize bodies or to subjugate the subjectified body.4

Foucault suggests the body is largely a force of productioninvested:

. . . with relations of power and domination;but,on the other hand,

its constitution as labour is possible only if it is caught up in a

system of subjection (in which need is also a political instrument

meticulously prepared, calculated and used); the body became a

useful force only if it is both a productive body and a subjected body

(p. 26).4

The subjectified body is useful only as far as it is productive.Therefore, the poor, who were unable to find

employment, appeared to be stigmatized by nineteenthcentury English society as unproductive. Therefore, theywere viewed as a burden on the State.5

TRADITIONAL WOMEN’S ROLES ANDTHE GROWTH OF FEMINISM

British society valued women for their reproductiveability and believed that women were intellectually andphysically inferior to men. Women were encouraged to be docile, self-sacrificing, obedient and pure. If womendid not conform to this stereotype they were reviled asamoral.6 Traditionally, middle class women were educatedby their mothers, grandmothers and aunts to becomedutiful wives, who upon marriage relinquished ownershipof any lands or wealth they may have possessed to theirhusbands.6 As wives, middle class women were expectedto nurture children, to provide their husbands and chil-dren with moral guidance and to assist in the moral devel-opment of the socially inferior. Middle class women werenot expected to work in paid employment, but wereencouraged by society and religious tradition to engage incharitable activity directed at changing the behaviours ofthe working classes. Working class women were consid-ered by their social superiors to be ‘morally suspect’.6–7

NIGHTINGALE AND PROFESSIONAL NURSING

Florence Nightingale emerged in the early nineteenthcentury as an advocate for the professionalization ofnursing and, inadvertently, for women’s enfranchisement.Nightingale was not predisposed to marriage and re-cognized an opportunity to advance career options forsocially advantaged women.6,8 She admired the work ofthe Catholic religious women nurses and spent time witha Protestant order of Deaconesses in Kaiserswerth,Germany, studying nursing. With the outbreak of theCrimean War, Nightingale advocated for professionalnurses to accompany the British soldiers to war. Sheargued that trained nurses, who were Catholic, supportedthe French army.8 These nurses, she asserted, reduced the morbidity and mortality of men engaged in the warbecause of their nursing skills.8,9 Nightingale’s testamentto the expertise of the French Catholic women, coupledwith Britain’s dependence on the working classes for economic productivity and the presumed threat ill healthand immorality among the poor posed for the sociallyadvantaged of society and national security, provided

Service to the poor 171

the impetus for women to challenge traditional genderroles.1,7

THE EMERGENCE OF HEALTHVISITING AND DISTRICT NURSING:

STRATEGIES TO DEAL WITH THE POOR

As Britain’s population increased, particularly among theworking classes, so did the demands on the State for healthand welfare assistance. Outdoor assistance was limitedfrom 1834, thus providing some relief on the Poor Laws,and increasing assistance was provided on an indoor basis.1The State stipulated that work-houses should not beattractive options for the poor, therefore the poor weredissuaded from accessing the facilities by making lifewithin them difficult. This attitude was supported by a coexistent philosophy that supported the notion thatindustry and productivity were ordained by God, and,conversely, that idleness was sinful.6

During the nineteenth century, there were moremiddle class single women than men.1 This phenomenon,coupled with society’s view of femininity, led sociallyadvantaged women to explore socially endorsed alterna-tives to marriage. Activities such as home nursing of thepoor were popular and advocated by societies of women.The main proponents were Elizabeth Fry’s ProtestantNursing Sisters, the Gloucester District Nursing Societyand the Ranyard Missionary Ladies.6 Their work was inkeeping with society’s view of what was acceptable femi-nine behaviour for women and also assisted the State tomonitor and influence the behaviour of the poor.6 In 1859,William Rathbone employed Mary Robinson to workamong the poor in Liverpool, England.7 Dingwall et al.suggest that Rathbone was the first person to use the term‘district nursing’.6 Although his scheme was not new, itwas innovative because he recognized the need for ‘dis-trict nurses’ to be trained nurses, which was a positionsupported by Nightingale who stated that the districtnurse must ‘. . . be of a yet higher class and of a yet fullertraining than a Hospital nurse . . .’6

Nightingale believed that district nurses should bemore highly trained than hospital nurses because theirpractice occurred outside the controlled environment ofhospitals; a view that Rathbone accepted. In 1887, QueenVictoria supported the establishment of the Queen Victo-ria Jubilee Institute for Nurses, which was chaired byRathbone and followed the model he had developed.TheQueen’s Nurses as they became known, were recruited

from groups of women who had completed a nurse train-ing course in an approved hospital. Once employed, thenurses completed an additional training period in a District Nursing Association in district nursing.10

In addition to the various home nursing organizations,women’s societies were formed to teach working classwomen about domestic hygiene and child health.6 It was argued that if working class women accepted middleclass values, then the threat posed by the immorality of the poor would be addressed.5–7 Moreover, concern about national security in the wake of the Crimean War prompted authorities to consider the health of theworking classes.1 Health visitors were engaged to monitorsanitary living conditions and to educate working classwomen on domestic hygiene and child nurturing, activi-ties that were accepted by society because they maintaineda veneer of femininity.5–7 Eventually, health visitors wereexpected to be trained nurses, and hold a qualification insanitation and either midwifery or obstetric certificates.Therefore, district nursing and health visiting became spe-cializations within nursing; a development supported byeducated women who sought avenues for career advance-ment that guaranteed influence and respect.7

IRISH CATHOLICISM AND THE POORThe Catholic Church in Ireland, like England, was sacked under Henry VIII and outlawed.2 Catholicism wasrenounced by the crown and the Protestant Church ofIreland was declared the ‘true’ church of Ireland. WhileEngland accepted the loss of Catholicism and embracedProtestantism, in Ireland Catholicism continued to bepractised by the majority of the population. The BritishCrown attempted to break the hold of the CatholicChurch in Ireland and passed a series of laws, the Penal

Codes (1703), which outlawed Catholicism, the clergy, andprevented Catholics from owning land, thus prohibitingCatholics from participating in political life.1 The work ofthe Catholic clergy and the religious orders in Ireland con-tinued, with many new religious orders emerging to dealwith the plight of the poor in the wake of the devastationcaused by the industrial revolution and England’s demandson Ireland following the Napoleonic Wars.11

IRISH CATHOLICISM AND FEMINISMWomen within Catholic society, like their ProtestantEnglish counterparts, were encouraged to make success-ful marriages and to produce and nurture children.11

However, Irish middle class Catholic women were better

172 K. Francis

educated than their Protestant English counterparts.Many Irish Catholic women were sent abroad to study inthe Catholic countries of France, Spain and Italy.7 IrishCatholic middle class women who chose not to marry had the added option of taking religious vows, which wassocially acceptable and openly encouraged by Catholicfamilies and the Catholic Church.12

For Catholic women there was opportunity within theframework of religious orders to aspire to and achievepositions of power within the congregation and the widersociety.12 However, because the Catholic Church is basedon a patriarchal structure, religious women had to adhereto conditions determined by the Church.13

Throughout the nineteenth century, the number ofsocially advantaged Catholic women joining religious congregations increased. New orders of religious womenwere founded, which modelled congregational rules oninnovative practices that permitted religious women to participate in society. Uncloistered religious womencommanded respect and were influential within society.Moreover, these women were well received by theChurch, which needed assistance to support the increas-ing numbers of poor, and nursing and education of thepoor were identified as appropriate apostolates of care.7

CATHOLIC RELIGIOUS WOMENThe Irish Sisters of Charity founded by Mary Aikenheadin 1815, and the Sisters of Mercy founded by CatherineMcAuley in 1827, discarded their lives in the cloisters tolive and work among the poor. Both these orders under-took nursing and teaching as strategies to enhance the livesof the poor as well as to expand their own career options.7

As religious women, they were bound by their vows,including poverty, chastity and obedience; however, asEckenstein argues, religious women were able to aspire toand achieve positions of influence within the congregationand were respected by the society.12

RELIGIOUS WOMEN SERVE THE POORAND THE STATE

As in Britain, advances in agricultural practices and indus-trialization impacted on traditional ways of life. Peoplemoved from rural areas to the cities seeking employment;consequently, the numbers of urban poor increased. InIreland, the State introduced the work-house system in 1838 to provide in-house relief to the aged, frail,orphaned and sick. In addition, Catholic religious womenestablished health services that included home visiting

and the founding of hospitals, hospices, orphanages andschools for the education of girls and women.14 Catholicreligious women were accepted by the Irish poor becausethey were Irish and willing to work and live among them.7

From 1832, Ireland was ravaged by plagues of cholera.The Catholic poor of Ireland were distrustful of the Anglo-Irish authorities and refused to be admitted to theState voluntary hospitals.The authorities realized that theplague could only be controlled if victims were isolated.Catholic religious women assisted the State by encourag-ing the poor to go to hospital and volunteered to nursethe sick in the State hospitals.

Unlike hospital nurses who were illiterate, untrainedand working class, Catholic religious women were edu-cated ‘ladies’ accepted by the Catholic poor because theywere religious women who were willing to work and liveamong them.7,9

PROFESSIONAL NURSING ANDMEDICAL PROFESSIONALIZATION

IN IRELANDThe large numbers of people affected by the choleraplagues and concerns that the spiritual needs of Catholicswere not being met in the voluntary Hospitals led MaryAikenhead to found the first Catholic hospital, St Vincent’sin Dublin in 1834.14 Mary Aikenhead sent three of hernuns to France to train as nurse-apothecaries and hospitalmanagers.10 She advanced the idea that trained nurseswere required to provide skilled care, a notion that Florence Nightingale was also beginning to contemplatein England. To guarantee medical treatment of the hospi-talized poor, Aikenhead appointed honorary surgeons and physicians to St Vincent’s. Honorary medical appoint-ments were sought as they provided medical practitionerswith income in a market over-supplied by medical practi-tioners, and allowed medicine the opportunity of advanc-ing knowledge through the study of diseases processes.15

Following the establishment of the first Catholic Univer-sity in Ireland in 1858, Aikenhead consented to a ClinicalSchool of Medicine being established at St Vincent’s inDublin. The clinical school concept was advocated bymedical practitioners as it provided students with anopportunity to study disease and treatment modalities.Moreover, skilled educated religious nuns trained asnurses were supported by the medical profession becausethey required educated, obedient nurses to monitorpatients in their absence and provide treatment as they

Service to the poor 173

directed.The Clinical School of Medicine also guaranteedAikenhead inexpensive medical support for the pooradmitted to the hospital.7,15

In the absence of welfare assistance from the State, andprior to the introduction of the Irish Poor Laws in 1838,Catholic religious women visited the sick in their homesand provided alms to the destitute. The nuns continuedtheir home visitation programmes following the estab-lishment of hospitals, but nursing care was increasinglyfocused in hospitals because medical assistance was avail-able, spiritual guidance was more easily provided and thepatients could be cared for and nourished in environmentsthat the nuns believed promoted wellness.7,14

TRANSPORTATION:THE PENALCOLONY OF NEW SOUTH WALES

The swelling population of England and Ireland during thenineteenth century, and the displacement of rural poor tothe cities, resulted in a growing population of urban poor.Increased hardships experienced by the urban poor, whowere unable to find employment or whose employmentreturned wages that were insufficient to meet the costs ofliving, resulted in an associated increase in crime.1 Britishprisons were unable to cope with the number of peopleincarcerated. America, having declared its independence,refused to accept convicts, and a new method or place fordisposal of convicts was sought. New South Wales wasidentified as a suitable repository for convicted felons withthe first fleet arriving in Botany Bay in 1788.1,15,16

As a British colony, Protestantism was the establishedreligion; however, one-third of the population through-out the transportation period was of Irish Catholic heri-tage. Moreover, men outnumbered women three to one.7

Women convicts were regarded by society as ‘damnedwhores’, an image that was perpetuated throughout thenineteenth century.7

Catholicism was regarded with suspicion by the Britishauthorities because they believed attendance at masswould be used by the Irish to incite sedition.17 However,the Irish Catholic Church was permitted, from 1803, torecruit clergymen to undertake service in the colonywithin strict guidelines established by the colonial authorities.7

COLONIAL HEALTH CAREFrom humble convict beginnings, the colony of NewSouth Wales expanded and assisted immigration of free

settlers secured the success of the colony and added to theburden on the authorities to provide services includinghealth care, welfare, education and housing.18 Five colo-nial surgeons accompanied the first fleet and establishedthe first convict hospital, the Sydney Infirmary. From thebeginning of white colonization, the medical professionwas able to establish a position of power. The colonialmedical officers were members of the colonial militia and also members of a necessary profession with limitednumbers of practitioners in a climate with no competitionfrom other health care providers.7,19The colonial surgeonsprovided medical care to the convicts and the colonial military. Nursing care was provided by convict womenand men incapable of being assigned to manual labourbecause of infirmary, illness or advanced age.7,20

The colonial authorities supported the establishedchurch and encouraged philanthropy by the wealthy as astrategy to encourage the colonists to provide assistanceto the non-convict members of colonial society. Thisreduced the financial burden incurred by the introductionof State health and welfare initiatives.19,21

The doctrine of the established church taught that thewealthy were obligated to provide spiritual and physicalassistance to members of society considered to be deserv-ing. In addition, the Catholic Church was supported by the colonial authorities to expand, because the church waswilling to support the Catholic poor, who otherwisewould have been a burden.7

In 1813, the first charitable society, a Protestant phil-anthropic society, was established by eminent colonialmen to teach Protestantism and to provide assistance tothe deserving poor.The Benevolent Society of New SouthWales, as it was known from 1818, founded an asylum forthe destitute, ill, aged, orphaned and pregnant unmarriedwomen. Within the asylum, honorary surgeons providedmedical care, while nursing care was provided by ableinmates of the asylum. Only limited outdoor relief wasprovided as the focus of the society’s functions was indoorrelief.

For medical officers attempting to establish fee-for-service private practice, appointments as honorariums atthe Benevolent Society Asylum, and later at St Vincent’sCatholic Hospital, assisted them to gain a reputation.21Theburgeoning of private medical practices was coupled withrestrictions on medical practitioners’ time.Therefore, thehospitalization of patients was justified because many ofthe colonial poor lived in squalid conditions and werepoorly nourished, and demands on the medical practi-

174 K. Francis

tioners’ time for travel to visit patients in their homes wasreduced.7,19

CATHOLIC RELIGIOUS WOMENADDRESS THE NEEDS OF THE

COLONIAL POORThe Catholic Church was active in providing pastoral careto Catholic convicts from 1798. However, it was not until1838, under the leadership of Bishop John Bede Polding(the first Catholic Bishop of New South Wales), that thefirst Catholic women arrived in the colony to expand theCatholic Church’s pastoral programme to include nursingand the education of children and women.

Bishop John Bede Polding acknowledged the poverty inwhich the Catholics of Sydney lived and recognized a needfor trained nurses to care for the poor.13,14 Knowing thework of the Irish Sisters of Charity, he approached MaryAikenhead who sent a contingent of five religious sistersto New South Wales.7,19

The work undertaken by the Sisters of Charity includedthe establishment of a school for poor children, the visitation of the sick poor in their homes, working withwomen prisoners at the Parramatta Infirmary, nursing inthe convict Hospitals in Parramatta and Sydney, and thefounding of a refuge for single women and an orphanagefor Catholic children.7,13,14,21 Throughout the nineteenthcentury, the numbers of single women with dependantsrose. The colonial authorities advocated marriage and provided incentives for men willing to marry; however,women were not well regarded. Therefore, women andchildren became the focus of the activities of the nunsfrom the time of their arrival in the colony.14

PIOUS WOMEN AS PROFESSIONALNURSES ACCEPTED BY

COLONIAL SOCIETYTwo of the Sisters of Charity were trained as nurses, wereskilled in Hospital management and had apothecaryknowledge.2,14 Brodsky notes that Sister M. Baptist deLacy was regarded by a member of the community asbeing the only person in the colony qualified to be amatron of a hospital.22 In keeping with the traditions of their religious order, the Sisters of Charity opened StVincent’s Hospital in Sydney, the first Catholic Hospital inthe colony. Unlike the nurses employed in the colonialconvict hospitals, who were described as a ‘dissoluteclass’, the Sisters of Charity were well-educated, middleclass Irish women respected by society because of their

piety and willingness to work among the poor.7,20,22 Asnurses, the nuns were skilled, efficient, educated and obe-dient, qualities medical practitioners applauded.19

MARGINALIZATION OF COMMUNITY NURSING

From 1838, the Sisters of Charity began a tradition ofnursing excellence in New South Wales that focused onproviding for the needs of the poor. Miller suggests thatthe reputation of the sisters as skilled nurses spreadthroughout the colony.24 Honorary surgeons employed bythe State hospitals, perhaps as a result of the reputation ofthe nuns and exposure to working with skilled nurseswhile completing post-certification studies in Britain andEurope, demanded the recruitment of professional nursesto staff the hospitals.8

In the absence of other services directed at caring for the poor in their own homes, the Sisters of Charityadvanced community nursing practice. However, sustain-ing the level of assistance required by the colonial poorwas difficult for the nuns. Colonial boundaries wereexpanding, which increased the distances the nuns neededto cover in order to visit the poor in their homes. More-over, medical support was limited by the numbers ofmedical practitioners in the colony, the demands on thetime of the medical officers in service of the State, privatepractices and their obligations as honorariums.19–21

Growing concern about meeting the needs of the poor,coupled with the nuns’ inability to attract large numbersof postulants and their belief that the most appropriateplace to care for the sick poor was within the controlledenvironment of a hospital (a view supported by colonialmedical practitioners) led the Sisters of Charity to openthe first Catholic hospital, St Vincent’s Hospital in Sydneyin 1856.14,22,25 The opening of St Vincent’s Hospital was astrategic initiative by the Sisters of Charity. The Sistersfound it difficult to recruit postulants so the effectivenessof the services they provided through their pastoral careprogramme and their voluntary work at the convict hos-pitals (which were resource intensive) were not sustain-able. It was argued that there was little that could beachieved by skilled nursing if the living conditions inwhich the poor lived were not conducive to wellness.13,22

Therefore, the Sisters of Charity rationalized services,including their home visitation programme, following theopening of St Vincent’s Hospital.

Hospitalization of patients was an effective and efficientmeans of maximizing the Sisters of Charity’s resources.As

Service to the poor 175

patients of St Vincent’s Hospital, the poor were guaran-teed medical care from honorary surgeons and receivednursing care from trained nurses in an environment thatthe religious women and medical officers consideredfavourable to the promotion of health.20 In addition, thespiritual well-being of patients was more effectivelymanaged as the nuns provided care on a 24-hour a daybasis.7

CONCLUSIONThroughout the nineteenth century in England, Irelandand New South Wales, the poor were identified as a threatto society. In England and Ireland, socially advantagedwomen used prevailing social conditions to advocate fornew roles for women. The poor became the objects ofsocial planning and philanthropic endeavours. In England,health visiting and district nursing emerged as specialistareas of nursing, established to provide women withsocially endorsed career options and as mechanisms tomanipulate the behaviours of the poor. In Ireland and inNew South Wales, Catholic women pioneered professionalnursing, within the framework of the male-dominatedhierarchical system of the Catholic Church, to meet theneeds of the poor. As in England, the Irish poor and theAustralian colonial poor were poorly regarded by societyand the State. Moreover, as in England, the needs of thepoor provided Catholic Irish women with an opportunityto challenge tradition. New orders of Catholic religiouswomen emerged, which accepted the plight of the pooras the basis upon which to found innovative congregations.Unlike the women of England, Catholic religious womenwere bound by vows that precluded them from seekingworldly recognition for their activities. As members of areligious community they were obligated to consider thecommunity and the wider congregation at the expense ofself.12The nuns visited the poor in their homes and nursedthe sick in the convict hospitals as required. The poor,medical practitioners and the colonial authorities acceptedthese Catholic women because they were pious and posedno threat to the position within health care that themedical profession was assuming.7 As the colony grew andthe demands on the nuns to support the poor throughtheir health, welfare and education programmes bur-geoned, new approaches to service provision were sought.The opening of St Vincent’s Hospital provided a cost-effective and efficient method of caring for the poor andwas accepted by society and the medical officers. Com-munity nursing, which was practised by the nuns, was

therefore inadvertently marginalized by religious womenwho believed care for the poor was qualitatively improvedif they were nursed in the controlled environment of ahospital.

ACKNOWLEDGEMENTSI wish to thank Professor Alan Pearson for his guidanceand supervision in my doctoral thesis from which thisarticle emanated and also Charles Sturt University forfinancial and resource support throughout my candida-ture. Gratitude is also due to Ysanne Chapman for herassistance in the preparation of this paper.

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