When nurses took their place in Danish psychiatry

Danish version / Dansk version 

Introduction

Denmark's psychiatric nurses came into being in the crossroads between two parallel events in the nineteenth century.

The first was that psychiatry became a medical specialty. Early in the nineteenth century, lunatics were sent to poorhouses, jails or madhouses fitted up as prisons. The popular pressure on politicians to make the conditions of insane people more humane increased throughout the century. The authorities responsible for the welfare of insane people were separated from those responsible for the welfare of poor people, and in 1884 the state took over responsibility for insane people, since the individual municipalities had difficulty in discharging this responsibility because of the fiscal burden (1:21-28).1 Pressure on politicians, mainly from physicians, led to the construction of large curative asylums throughout Denmark for nearly a century beginning in the 1850s. Simultaneously with this humanistic current, which is historically linked to the Enlightenment, attitudes towards mental illness changed. Instead of previous attitudes towards mental illness as being supernatural or a moral flaw, a lunatic was now considered mentally ill and became the object for the objectivizing empiricism of medicine.

The other event was the constitution of the trained nurse. In 1876, nursing at the Copenhagen City Hospital was reorganized to realize the demand for improved nursing.2

These demands were increasing in step with the increased potential for medical treatment. A practical training course was established mainly targeting women from the socially advantaged classes. Although the objective of recruiting from the cultivated classes did not succeed completely (2:57, 3:66), the reorganization contributed to increasing the very low social prestige associated with nursing and thereby made it a socially acceptable profession for the young women of the middle class.

With few exceptions, trained nurses began to be employed later in mental asylums than in the somatic hospital system (2:3).3 In 1911, the Act on the Organization of Conditions of Care at State Mental Asylums was adopted. This Act stipulated that the untrained personnel must be replaced by trained nurses based on the requirements of the patients in such a way that the to-tal personnel expenditure would not increase (4:\4711).

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The same Act states that all the nurses at the state mental hospitals were employed after 1900.4

This article aims to describe and explain how somatic and practically trained nurses were able to move into the mental hospitals without any actual professional traditions.

Method

The article is based on Michel Foucault's (5-7) methodical framework for historical discourse analysis. Foucault's framework for analysis and philosophical viewpoint are relevant here because he insisted on dissolving current institutions into their history so that they do not appear inevitable and natural to the observers of the present. Foucault never described any exact procedure. He describes, in contrast, in a somewhat experimental and retrospective manner, the considerations related to what discourse analysis could contain and considerations on the function of discourse in speech and in social life (7).

Foucault uses the concept of discourse in (at least) three overlapping senses (6:80):

1. As an expression of speech: the general domain for all statements;
2. As a group of statements that can be distinguished from speech: discursive formations, which are linked by various rules for formation and not by the topic or author of the speech; and
3. As the practice of regulated language, which supports and maintains a certain discursive formation.

Key to these three meanings is the concept of a statement, which Foucault defines negatively: that is, as differing from a logical proposition, a sentence or a speech act. He asserts that a statement is a function that acquires content by crossing various discursive structures and linking them with other statements (6:79-87): that is, that language has a function in creating meaning. Foucault insists on investigating a statement in its positivity, which means that it must not be reduced by enquiring about its meaning or the intention behind it. Instead, the question is which external conditions of possibility exist so that a statement might arise with a specific material content at a given place and a given time.

The statement acquires content through its function and creates opportunities for social phenomena through articulation. The statement thus contributes to controlling the objects about which one can speak and know something, and this is the key to the inextricable link between the statement and power. Foucault emphasizes four discursive elements in his description of discursive formations (6): Objects, enunciative positions, concepts and strategies. A statement enables the various discursive elements in speech, and a statement can be identified through this function. This means that a statement is a statement when it articulates an object, an enunciative position or a concept in a discursive formation, which is the organized regularity of discourse.

The perspective

This analysis constructs a specific perspective on the texts on which the analysis is based. The focus is determining the object of the investigation, the historical periods and selecting the texts. The object of the investigation is nurses' work at mental hospitals. This means searching the texts for every context in which nurses are described in their work. The period is the 12 years from 1900 to 1911, in which nurses started to work in large numbers at the mental hospitals. The year 1900 was chosen for the pragmatic reason that Tidsskrift for Sygepleje (the present journal) began to be published in 1900 and can be used as a source. In 1911, the Act on the Organization of Conditions of Care at State Mental Asylums was adopted. The 12-year span of this period is useful since it does not extend through a shift in the attitudes towards nurses' work but is simultaneously long enough to capture the discursive regularities. The text material was selected in advance based on assumptions about its relevance. One source is the only Danish textbook on mental health care: Vejledning i Sindsygepleje (Guidebook on Mental Health Care) by Jacobsen & Krarup (two physicians). Others include chapters on mental health care from the books Haandbog for Sygeplejersker (Handbook for Nurses) by Jacobæus, Kiær & Salzwedel and all articles on mental disorders, mental health care and psychiatric nurses in Tidsskrift for Sygepleje. The sources were chosen to enable both the statements of leading experts and alternative statements from clinical nurses. The source material could ideally have included even more diverse forms of material: diaries, internal educational material, newspaper debates, registers of complaints and dismissal cases and others.

The perspective is constructed based on three foundations. The first is based on the theory of

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recognition. The perspective creates an interface from which a discursive formation sporadically may be studied without assuming the truisms of the discourse (cf. 5:311). The historical perspective reduces the risk that the truisms of the discourse might be assumed unconsciously. Second, the perspective enables others to study the analysis. Third, an exact perspective allows for comparison between this study and the perspectives and findings of other studies.

The starting-point for analysis of discourse is identifying the statements in texts. The introductory feature of the analysis is finding all the statements in which nurses' work is described: psychiatric nurses are the discursive object to be searched for first in the texts. When the nurse as a discursive object has been identified, the objects that appear together with the nurse are then analysed. Then the enunciative position from which the statement arises is analysed and, finally, the concepts used in the statement are analysed. The analysis is controlled and specified through a set of detailed questions for the statements at these three levels of analysis. The results of the analysis appear as descriptions in a mosaic with three strata, in which strategic contexts can be inferred across these three strata abductively.

Most of the statements in the text material are located in the same way in the mosaic: nurses are often described similarly from the same enunciative positions and using the same concepts. This article therefore only refers to a small portion of the total text material.

Results

The results present and summarize numerous discursive statements, concluding by describing the discursive strategies that account for the regularity of the dispersal of the statements.

Humanistic medical science

Jacobsen & Krarup began their book by stating that ''Mental illness is somatic illness'' (8:IX). This summarizes the definition of mental illness physicians advocated in the early twentieth century. The medical understanding of mental illness is portrayed as ''a more true conception of the essence of mental illness'' (8:IX). Jacobsen & Krarup indicated that the mediaeval notion of mental illness was possession by demons or the like and that, until very recently, mental illness had been solely treated by protecting society from mentally ill people through confinement (8:IX). There is thus a substantial distinction between the conception of lunacy held by the clergy and public authorities and physicians' conception of mental illness.

Jacobsen & Krarup wrote that the treatment of insane people had been based on minimizing the use of force since the French physician Pinel reformed the principles for treatment at the turn of the nineteenth century. The medical conception and treatment of mentally ill people therefore expresses interest in the welfare of mentally ill people and thus humanism. The principles of treatment aim, as with all other types of illness, to arrange the living conditions of ill people so as to heal or reduce suffering (8:X, 97). V. Christensen (a physician) claimed that care aims ''to protect the patients from themselves'', since they are dangerous both to their surroundings and themselves (9:194). Nursing at mental hospitals had been performed by less cultivated people who had not understood that lunacy is illness (9:75, 10:60).

The key to this explicit strategy is linking humanism and the medical conception of mental illness as somatic illness. Alternative conceptions of lunacy thereby become not merely false, since they contradict medical science, but are also morally despicable since the medical conception is humane ü a moral asset. Patients are no longer confined to protect society from patients. Patients must be protected from themselves; they are confined for their own good.

The mental hospital is the place where the patient is safeguarded from mental turmoil. The hospital is divided so that patients with the same types and stages of illness are located in the same department (8:115). The literature in Denmark describes observation departments, transitional departments, convalescence departments and care departments. The various departments are distinguished by the degree of supervision and by the freedom of patients to move around on the hospital's premises. Patient's healing requires remaining at the hospital under the organized and adapted conditions. This is why patients may not escape (8:141-142).

''In addition to ensuring these somatic hygienic conditions, one must ensure in the treatment of insane people that, also in the spiritual sense, everything that has contributed to triggering the disorder is kept away from the patients to the extent possible. They must therefore be protected against everything that could be considered from an external viewpoint to bring disorder

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into their minds, and it is precisely this task that mainly gives mental hospitals their extraordinary characteristics. For this reason, one attempts for a while to keep patients completely cut off from connections with their usual conditions, among other things, by not allowing them to have visitors or letters, and this comprises part of the reason for the confinement that cannot be avoided in treatment of mental illness and that may easily appear to be coercion but in reality is only protection.'' (8:112-113).

The hospitals' treatment of patients is discursively constructed as being for the patients' own good and not as an expression of coercion. This articulation is enabled by the humanistic discourse and is necessary, since the hospitals' practice could easily be considered coercive.

The desire to heal patients generated a new type of medical attention targeting the conditions of patients. Somatic and spiritual illness are articulated in patients, and the patients thus become an object for medical science.

Direct intervention in care

Jacobsen & Krarup wrote that the soul and body are inextricably intertwined, but since the manifestations of mental illness differ sharply from those of somatic illness, the symptoms are described separately (8:XI, 97). The body is the principle that organizes the body's structure and manifestations. Both treatment and care follow the nearly deductive logic from anatomy to dysfunction to treatment and nursing care; nevertheless, whereas treatment targets healing, nursing care targets palliation.

Hygiene is a common objective of the care given to somatically ill people and mentally ill people and includes both the patients and the physical environment: ''The main necessity in this respect, as in all treatment of illness, is to fully satisfy the usual hygienic (health) requirements in the realms of diet, air, light, heat and cleanliness.'' (8:109).

Modern psychiatric care follows the usual objective of treatment and nursing care to heal or palliate by arranging the living conditions of mentally ill people favourably (8:109). The appropriate mental health care is inferred from the manifestations and forms of mental illness. For example, stupour is cared for by constantly promoting activity; confusion (such as insecurity, turmoil or uncleanliness) should be healed with supervision, care, rest and cleanliness (8:101-102). The key seems to be combating anything with a negative prefix: disorder, unrest, unease, disquiet, disturbance, insecurity, uncleanliness, dissension, discord, irregularity, uncertainty and unworthiness. Suicide (also to be combated) is an exception from the negative prefixes. (English seems to have more negative terms without prefixes than Danish, such as agitation, turmoil and accidents.) The negative prefixes denote the deviation assigned to the patients and their behaviour.

Rest is a treatment principle to protect against physical and mental unrest (8:113). Just as every other diseased organ requires rest, the brain of a person with a mental disorder requires rest and must be protected from stimulation. Rest includes such concepts as balneotherapy, wet wraps, isolation and rest in bed. After achieving a state of rest, a patient should be strengthened through regular and organized activities (8:117), including both work and recreation. The discursive regularity directly counteracts the patient's condition. The intervention therefore begins by combating unrest directly and then lethargy.

Mental health care comprises daily contact with patients, observing the patients' bodily and mental peculiarities and actual psychiatric nursing care (8:118ff). The observations include eating, menstruation, sleep, speech, fever, pain, signs of violent behaviour and the overall manifestation of a patient. Caregivers must observe a patient carefully and report everything precisely to their superiors and/or a physician (8:117). The nurses' observations must always be covert, such that the patients do not feel that they are being observed (9:192). The actual care comprises assisting patients when they cannot perform activities and preventing them from hurting themselves (8:128). The actual treatment of a patient is linked with prescribed and tempered work and recreation. Patients should participate in daily housework (8:144).

Somatic health care and mental health care differ substantially, but they both follow the same discursive regularity, in which one can conclude logically from illness to treatment and also directly intervene in the course of illness. This discursive practice affects access to the discourse. Illness is defined based on the enunciative position of humane medicine: ''Where the illness is located and its nature are naturally decided by the physician.'' (8:10). Since nursing care is direct intervention targeting illness, it follows that the content of mental health care is determined based on the articulation by medicine of patients

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and the treatment and care they receive. An enunciative position is created based on the humanistic and medical strategy in which physicians acquire a monopoly on speaking about mental disorder, patients, treatment and mental health care.

Physicians' monopoly is based on the scientific approach, which is protected from other enunciative fields within the discursive formation. Christensen called the ''scientific nurse'' an abominable plague. Nurses have nothing to do with science. Nurses should therefore observe for physicians by being their surrogate eyes and ears, but actually examining patients is out of the question (9:192-193).

Caregivers are physicians' helpers: The link between the physician and the patient (8:119). For example, when patients are violent: ''For caregiving personnel, the task is always solely the temporary neutralization of the patients, whereas actual treatment of the bout of unrest is reserved for the physician.'' (8:134). Another example is if a patient is injured and first aid is given: ''The first rule should be that caregiving personnel always, as soon as possible, must summon a physician, but until the physician comes, must provide the appropriate help.'' (8:62). The conceptions of caregiving personnel on care are thus always constructed through discourse as being tentative and are disregarded when the physician is present.

Nurses must thus articulate their work without any scientific approach. They are not capable of establishing the content of nursing (the what of nursing), since this is established based on the enunciative position of physicians through discursive practice. Instead the practical performance of care becomes key (the how of nursing). Charlotte Munck, a nurse, reviewed Jacobsen & Krarup's book and longed for ''the day when one of our own, a skilled, conscientious and experienced nurse, analyses this matter from our viewpoint and gives us a really valuable book on 'practical nursing''' (11:85). Munck attempts to articulate the work of mental health nurses as moral skill based on experience, and this enables the specialization of psychiatric nursing of another type than the medical type (10:65).

This attempt to specialize results from exclusion. The enunciative position of physicians comprises a monopoly on making scientific statements about patients, treatment and nursing care, and nurses concentrate on the everyday things that women understand.

Rest, cleanliness and order

The physician is the highest authority. A physician must be contacted in all situations in which uncertainty arises on care or irregularities in general (8:23, 33, 134). The physician prescribes treatment: For example, whether a patient may have visitors or not, and the physician reads all letters to and from the patient. Physicians, with the chief physician at the top of the hierarchy, function as the overall agent ensuring that the conditions of the hospital are managed well because they define what is good or bad for the patients.

Caregiving personnel and the patients' everyday lives are described using the words interaction, behave towards (8:118-120), intermingle (9:190) and live with (12:42). Distinguishing social interaction from actual occupational therapy is actually impossible, since the patients and the caregiving personnel are also together during this work. In summary, the entire milieu of the patient is described as treatment (12:37, 13:289).

Cultivation is central in the discourse. P. Levison, a physician, believes that a good nurse with the proper cultivation is superior to or at least equal to the patient (14:155). Inpatients should again begin to live in everyday, homelike and ''natural ways'' (8:115, 117, 144). This model is not based on the patient's own home but on the orderly contexts found at the more open departments of the mental hospital. Thus, the words everyday, homelike and natural are used very narrowly. In these contexts, the work of nurses is explicitly linked to their ''natural'' femininity:

''[It is] clear, that the relevant position [the supervisor] is inherently definitely most suitable to be filled by a woman. Such a woman will undoubtedly give the place a much more beautiful touch of home-like coziness, if she has the appropriate domestic characteristics.'' (Professor K. Pontoppidan cited in (12:53)).

''Understanding'' that the ill person's actions are a manifestation of illness is demanded (8:121, 131). The traits of caregiving personnel are described precisely:

''Otherwise in living arrangements with mentally ill people, one should merely strive to behave moderately and naturally in all respects and demonstrate quiet and relaxed determination in association with mildness and friendliness. One must always be open and honest with the patients, never make promises one is not certain one can keep, and not under any condition deceive them in the least way, as through this they

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will not only stop trusting the relevant person but also all their other surroundings, by which will be lost one of the primary conditions for a positive benefit of their stay at the hospital.'' (8:121)

The only source that discussed psychotherapy is W. Morritt (occupation not mentioned), who claimed that nurses exercise the greatest influence by merely being themselves (15:241). This thus indicates awareness that ''something'' happens through personal influence, but there were insufficient discursive resources to justify this theoretically. The personal qualities are innate, provided by nature or achieved through the building of character (9:77, 12:289, 14:246).

This is not just any type of ''calm and natural'' behaviour. Self-restraint and patience are the most important character traits in working with mentally ill people. As described, nurses must not treat patients as they would other people. E. Seidemann (a nurse) wrote that nurses must never show that they are offended by the patients' harassment (16:204).

The natural behaviour of nurses is thus regulated by the understanding that the patients are ill and that their actions and speech are a manifestation of their illness. Nurses must thus be natural in a particular way.

Caregiving personnel must further demonstrate ''unconditional reliability and complete ability to obey their superiors and follow their instructions'' (8:119). These character traits differ from those mentioned previously, which were solely determined in relation to the patients.

The desirable characteristics of caregiving personnel are defined simultaneously in two contexts. The desirable behaviour is determined in part in relation to nursing care, which means what caregiving personnel must do to protect a patient and to counteract signs of illness, and in part in relation to the ability to dutifully obey superior authorities. In both cases, the physician is the highest authority. The order and discipline that is created to control, protect and care for the patient thus also includes the caregiving personnel.

Nurses and other types of personnel

Jacobsen & Krarup did not distinguish between types of personnel. The articles in Tidsskrift for Sygepleje do, in contrast. Nurses argue explicitly that trained nurses are needed. The requirement for caregiving hospital personnel is ''people who are cultivated, intelligent and of good character'' (10:60). Nurses are thus articulated through this discourse as an extension of the humanistic strategy. The existing caregivers are described as uncultivated and lacking the ability to understand the needs of patients for humane treatment and nursing care. This discourse constructs differentiation between nurses and other caregivers based on training, culture and cultivation. The difference between nurses and other caregivers is especially created through the equation of humanism and cultivation.

The nursing performed by trained nurses is called improved, rational and humane nursing (10:61, 63; 13:192). Nurses articulate themselves based on the ideals of surveillance and order, and they want to actively participate in effecting this at hospitals.

''[It is necessary] that there be a head nurse who knows her staff and can exercise supervision in daily nursing, which physicians can neither be expected nor demanded to take on, who has a sense of and understanding of placing the right people in the right places, who can separate the elements who turn out to be unsuitable for the profession and who, in cooperation with the physicians and as the responsible person reporting to them, can lead nursing at the entire institution into the direction that is established as the desirable one by the appropriate person.'' (10:63)

Nurses thus conducted discourse based on both the humanistic strategy and the order-creating strategy that already existed within the mental hospitals. Nurses did not threaten the position of physicians because nurses did not demand that they ''establish the course of nursing care'' and because nurses did not attempt to speak from a scientific position that could threaten the absolute dominance of physicians in the discursive formation of psychiatry.

Much of the work of psychiatric nurses thus became linked to meticulous surveillance of both patients and other caregivers. Nurses must be aware of the smallest details: ''a curtain string that is missing, a petticoat ribbon that has been torn off, a handkerchief that is lost or the size of the yarn with which the patient is knitting'' (9:197).

Order is considered to be positive, as part of the regularity that heals and protects the patients from themselves. In addition, order enables control through hierarchical surveillance of everyone at the mental hospital i.e. from chief physician to patients.

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The patients and their families
Patients exist through their deviations. They put objects into every bodily cavity, swallow toxic throat-wash, slit their wrists, forget to urinate, are stuporous and unwashed, smear themselves with or consume their faeces and remove their bandages. Christensen (9:194) claimed that one therefore can never feel safe around a mentally ill person. The patient is the embodiment of disorder. Nursing care and treatment target this clear mental disorder. The patient is therefore closely supervised to avoid further irregularities, such as attempting suicide or escape (8:127). Treatment and care aim to improve the patients' condition based on the norm from which the deviation arises and is defined. The need for treatment and care is thus defined normatively and is not based on the patients' subjective desire for treatment.

The patient's words are not taken seriously. The humanistic understanding of mental illness as somatic illness (and not a moral flaw) interprets the speech of the patient as a manifestation of illness. The patient's sick words and actions are incomprehensible and must be avoided. The patients' thoughts and speech must be diverted from the pain consuming their attention (9:193, 16:204, 17:475). Further, the nurses must not allow themselves to quarrel with a patient since they thereby sink to the patient's level (16:475). The nurses' state of cultivation thus enables distance to be maintained to the patients, whose speech is not assigned normal value or significance.

Christensen describes patients as ''life's most helplessly situated stepchildren'' (9:75). Neither mentally ill people nor children were considered to have social skills within the discourse of that era. The psychiatric discourse is the sympathetic monologue of reason towards mentally ill people, whose response has no significance (18:XII-XIII).

Relatives are mentioned very seldom. Family members have no place in the orderly conditions of the hospital, since they are part of the everyday life in which the patient has become ill and from which the patient has been removed. As described previously, visitors must be allowed only with the permission of the chief physician, who reads all letters (8:142, 146). The relatives' social skills are outside the discourse of psychiatry. The reaction of relatives to the admission of their family member is not articulated within the psychiatric discourse of that time. The texts did not mention the social function of the hospital, such as in implementing involuntary compulsory restraint.

Summary of the analysis

The analysis of the discursive formation of psychiatry allows three strategies to be identified that appear to classify the objects, enunciative positions and concepts of the texts. The strategies can only be distinguished analytically, since they overlap and influence one another. Humanism's ''understanding'' of lunatics as being mentally ill led to the establishment of large mental hospitals in which patients were restrained for their own good. The articulation of mentally ill people by medical science is inextricably intertwined with humanistic understanding. Illness, treatment, nursing care and the patient's objective deviations are articulated based on the enunciative position of medical science in the discursive formation of psychiatry. Inseparable from this is the demand for order, which seems to permeate the entire arrangement of the institution and organizes both the conditions of the patients and the hierarchy between the patients, untrained caregivers, trained psychiatric nurses, physicians and the chief physician. Treatment may be understood as continual disciplining of the patient's body and behaviour by continuing to monitor and prescribe work and recreation.

The entry of nurses into the discursive formation of psychiatry in the early twentieth century thus did not create a real rupture in relation to the existing strategies. The rupture created by nurses arose through a clear extension and refinement of the existing strategies and the articulation of cultivation to differentiate nurses from other caregivers. The notions of the work of psychiatric nurses are thus centred on humanism and cultivation, the ability to observe the patient appropriately in the absence of the physician and the ability to serve as both a responsible superior and an obedient and methodical subordinate. This conclusion explains how nurses' work has been able to be constituted without any previous formal traditions. There was no gap within the nursing profession, as the work and thereby the professionalism has been articulated based on bourgeois norms for proper behaviour. The work of psychiatric nurses was constituted based on ideas of social norms and not on actual knowledge of or experience with mentally ill people.

Nursing in psychiatry was constituted based on

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exclusion from a scientific approach, and talking about nursing as an independent profession is meaningless in this sense. The work of psychiatric nurses is described nearly without referring to specific knowledge about psychiatry. Personal characteristics are therefore strongly emphasized: hygiene and a sense of detail, ability to create a cozy, homelike and orderly milieu, household skills and a determined and patient appearance. These characteristics coincide with the ideal for women of that era: the housewife (2:90, 19:115-130, 20:180). The work of psychiatric nurses can therefore be considered to be ''public motherhood'' (20:179).

Discussion and perspective

The validity of this analysis should be assessed based on the validity of the constructed perspective (cf. 5:300): are the object of the investigation, the period and the texts selected relevant? The analytical limitation of the texts could be a problem. For example, in the early twentieth century, there were great debates on the relationship between nurses and physicians, on the adoption of a scientific approach in nursing and on the introduction of the Nightingale system (cf. 21). These debates were not common in the sources selected for this analysis but were, for example, in other articles in Tidsskrift for Sygepleje. Thus, there were currents in that era that are not captured by the perspective of this analysis and that will change the perspective and thereby the interpretation of the findings. This form of criticism could theoretically target any investigation that does not account for all texts and avoids source criticism. A further effect of the lack of criticism of the ability of the sources to explain historical events is that it is meaningless to claim that the analysis describes the past ''as it was.'' The analysis focuses on the discursive contexts existing at a given place and time. Most texts are written by experts, and everyday life may not have taken place within the framework of the discourse of experts. Further, this form of analysis cannot determine whether the nurses of that era felt oppressed or whether they found the discourse natural and considered the potential to specialize their everyday work as a beneficial alternative to the scientific approach of physicians.

This article presents Foucault's outlines for analysis in a very pragmatic and quasi-positivistic manner. The definition of the statement as a language unit that transmits meaning results in meaning being able to be sought regardless of intent and memory and being able to be treated ''objectively.''

Foucault's tendentious discourse positivism is rejected in the process of investigation by recognizing that the researcher is a necessary component of the abductive reasoning, which is the logical basis for identifying regularities in the identified statements.

Various questions on modern nursing care can be raised using the historical perspective.

Is psychiatric nursing care ''direct intervention'' arising from a medical definition of mental disorder? Is psychiatric nursing an attitude, a personal and perhaps feminine quality that cannot or should not have a scientific approach imposed on it? Does psychiatric nursing comprise close surveillance of the people at risk of developing symptoms of a mental disorder? Where has the explicit gender-based articulation of nurses gone? Does it exist today in more subtle forms, perhaps through such concepts as ''containing'' or ''holding''?5

References

For the references, see the Danish version.

Translation: David Breuer.

Notes 

1. The City of Copenhagen was an exception, as it continued to have its own authority responsible for mentally ill people, with Skt. Hans Hospital and Department 6 of the Copenhagen City Hospital.
2. This was not the first nursing education in Denmark. Both the Red Cross and the Diakonissestiftelsen (a foundation) had already organized brief training courses in nursing.
3. Department 6 of the Copenhagen City Hospital was an exception, as trained nurses began to work there under Chief Physician K. Pontoppidan in the late 1880s.
4. This Act had great effects. The exact numbers of nurses employed by the state were determined by counting based on the Finance Acts printed in Rigsdagstidende (the law report of the parliament). In 1900/1901, 11 nurses were employed in Aarhus, Vordingborg, Viborg and Middelfart. In 1910/1911, this number had increased to 36. In 1920, the total number of nurses employed increased to 171. The increase was most dramatic at the hospital in Nykøbing Sjælland, which was inaugurated in 1915. This hospital had 4 chief nurses and 5 senior nurses and a total of 56 nurses out of 141 total caregiving personnel.
5. Containing and holding are psychodynamic concepts used in nursing to describe and explain relational treatment.