Docia Kisseih, the first Ghanaian Chief Nursing Officer who researched on the history of her profession, states: “The care of the sick had been the prerogative of the elderly female members of the community before the advent of the professional nurse. Their skill was not acquired in any school of nursing but through long years of housekeeping and child-bearing and practical experience gained in the care of former sick relatives.” (Kisseih 1968). Like in many societies worldwide, the division went along gender lines, men being the healers and women providing the care.
Alongside colonialism and Christian conversion, European health care including its principles and convictions was introduced to Africa. The health hazards in the region claimed many lives and required improved health services for the Europeans there. In the early 19th century, the Basel Mission sent a medical doctor to evaluate the health situation in the Gold Coast. Like many men before, he “succumbed to the ‘fever’ within six weeks of his arrival” (Schweizer 2000). Only few European doctors withstood the challenges for a longer period and Europeans like Africans relied on traditional healers. In 1878 the first two European nurses arrived in the Gold Coast to care for the European officials, but it is not documented how successful their stay was. In 1892 a nursing organization was founded to send British nursing sisters to India to care for the colonial workers.
In 1895 the Colonial Nursing Associations followed, being renamed as Overseas Nursing Association (ONA) in 1919. Already in 1896 the first nurses were sent to Madagascar and as second place to West Africa, where they reached Accra to find out how the conditions for a permanent posting were. The objective was caring for the sick and maintaining a healthy living environment for both Europeans and Africans. The journey was successful, and its objectives fitted in the parallel expansion of the curative hospital-based health service in the region (Holden 1991). More nurses arrived by the turn of the century to establish a permanent nursing service in the Crown colony from 1899 onwards. These nurses were carefully selected and given the order to represent their home country and its moral norms and symbolize this order and discipline in their working attitude and spotless white uniform. This ‘right type of woman’ was often compared to a soldier, as Tooley does: “No pace is too remote, no climate too deadly for the nurse to ply her ministrations. Like the soldier she obeys the call of duty and if need be gives her life for the cause” (in Holden 1991: 68). Their main duty to work in the hospitals, assist the medical doctors and train local workers.
With the formal beginning of medicine in 1878, it became apparent that there were too few British nurses and that locals were needed to support the medical doctors, bathe and feed patients and dress their wounds. Most of the first Africans who were trained were male. Various reasons can be given to explain this fact. Firstly, women were supposed to fulfill the household chores and not expected to leave the compound for work other than farming or selling products in the market. Parents protected their daughters, since caring for strangers was perceived as unacceptable for girls in those days (Sumani 2005). In addition, this work required formal education in English writing and reading, and girls had not yet generally entered the school system. Sending girls to school was an economic risk, as they were supposed to be married and start child-bearing. Thirdly, men were seen as breadwinners to support their families. Sending them to school to acquire formal education was seen as a wise investment. But the nursing work in general had a low status. It is likely women took over the care of the sick and old in the families, but nursing was not yet perceived as a bread-winning lifelong activity. Working in these new institutions, the hospitals, where white doctors practised an unknown healing system appeared unattractive.
Another new factor was the content of work, namely dealing with naked bodies, blood, feaces, and smell; it was seen as menial work and not proper. The recruitment of candidates constituted a formidable problem from the start (Addae 1996, Kisseih 1968). Dr. Henderson, the then Chief Medical Officer, reports the same: “No native of intelligence would like to be a nurse because the pay is low and conditions of service are not good” (Owusu 1980). Those few men who were curious and courageous to work in the clinics were to be trained by the British sisters. This took place in the hospitals in Accra (Korle Bu), Cape Coast, Sekondi and Kumasi. The in-service education given to those candidates were practical instructions on the ward and theoretical lessons in anatomy and physiology, surgical and medical nursing and first aid techniques. Tutors assessed the students on the ward. There were no general standards in the training school yet, and also the educational standard of the trainees differed from a few year of schooling to Middle School Leaving Certificate. After a successful training of three years, a certificate was handed over and the men were appointed as Second Division Nurses in the Civil Services. They worked in the ‘junior service’; all senior posts like ‘sister’ and ‘matron’ were held by expatriates, and due to the limited training, there was no prospect of promotion for the African nurses (Kisseih 1968,Akiwumi 1994).
In addition there were orderlies for simple tasks like cleaning the floor and carrying messages. The differences in expectations and the religious and cultural background of the medical doctors, British and African nurses led to regular conflicts and frustrations. A surgeon complained in 1901: “I would strongly recommend that some steps be taken to encourage a better class of men to join this branch of the service, for really the type of boys we have applying recently are too bad for anything. They are all ‘bush boys’ who have had little education, so called, in a way of book work, otherwise they are absolute savages and quite untouchable” (Owusu 1981). The work was tediously divided in day and night shift with few free days and a strict disciplinary regime.
This all resulted in difficulties in retailing the trained nurses and recruiting enough new workers. At that time, the mining industry and cocoa farming had started to grow in the territories and many young men had migrated to those professions that promised a higher salary and less strict working conditions; the shortage of healthcare givers thus can be dated back to this very beginning. The British and African nurses worked together on the wards; while the British sisters supervised the work, dealt with the administrative writings and administered the medications, the nurses’ work was to clean and feed the patients, wash the bandages and clean the instruments. Bedsores were an indication for poor care rendered and its cause had to be explained to the matrons. Punishments and warnings were given.
Soon, plans were made to rethink the nursing activities and improve the training. The First World War delayed the development of the nursing education and reduced the number of British nurses from 64 to 15 by 1925, while there were about 100 male Second Division Nurses. Under Governor Guggisberg, the health delivery regained importance and new plans were made to reform the training and also attract women into the nursing profession. At this time, there was also another supporting profession at the hospitals, that of the dispenser: He was to performed sanitary inspection, treat complicated wounds and administer drugs. Indeed the status of such dispensers was higher than that of nurses and many motivated men changed into that profession, creating a shortage. Parallel to this, health visiting nurses took up work in Accra to help in the starting health welfare clinics. They can be seen as forerunners to today’s public health nurses (Otoo 1968).
The first midwifery school opened at the maternity block in Korle Bu, Accra, in 1928, and many girls who had passed through secondary education opted to enter into this considered female and accepted profession. The growing demand for Western healthcare demanded more nurses and a solution needed to be found to meet the need. In 1944 plans were made to establish a nursing education in the country, standardize the training and establish recognition with the British Nursing Society.
It is suggested that nursing started in most societies as a female activity, as caring for the sick family members in the houses was the duty of house-helps, wives and daughters. Healers and doctors needed assistants but organized the work distribution so that the glory of a successful healing was given to them, and the nursing activities were subordinate to them. In European hospitals, developing in the 17th century, the first nurses were nuns caring for the poor and sick brought there. Doctors emerged and displayed their knowledge there and the nurses were to support the medical treatment leading to healing or to give comfort to the dying with prayers on their last journey. Nurses were female and of unquestionable religious and moral status. Their devoted and endless commitment symbolized control over health threats and they were seen as perfect women and Christians. The first British nurses transported this image and expectations to the African colonies at the turn to the 20th century.
In conclusion, the start of formal nursing in Ghana shows an interesting development. While caring in the homes and compounds was the domain of women, nursing in health institutions was a new phenomenon. Cultural barriers forbade women to join the nursing profession, and it was male school-leavers who were trained as first nursing assistants. The European perception of the good woman caring for the sick could not be translated immediately into this context. Although working outside the house was possible for women, for example as market women or traders, dealing with sick strangers was initially regarded as inappropriate. It took time till formal school education was introduced and girls were admitted to secondary education. Secretarial work, teaching, and midwifery became options for those girls, professions that were imported from Europe and labeled as ‘typical female activities’. Nursing was added to that group of ‘female professions’ a slightly later. It underwent a change in perception and since it meant direct work under and with the colonial power, it was perceived as respected and venerable. The white nursing uniform intensified this idea. Some 45 years after arrival of the first nurses in the country, the nursing profession became attractive and accepted for women to choose after school education. It has to be seen that Western thought and standard dominated nursing in the Gold Coast.