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The Royal College of Psychiatrists Improving the lives of people with mental illness

The College Archives
An outline of the history of the examinations for mental nurses organised by the (Royal) Medico-Psychological Association


The Royal College of Psychiatrists was founded at a meeting in Gloucester in 1841 and was originally named the Association of Medical Officers of Asylums and Hospitals for the Insane. Samuel Hitch, the Resident Physician at the Gloucestershire General Lunatic Asylum organised the meeting and stated in his letter of invitation that his aims were 'that the Medical Gentlemen connected with Lunatic Asylums should be better known to each other, should communicate more freely the results of their individual experience, should co-operate in collecting Statistical information relating to Insanity and above all should assist each other in improving the treatment of the Insane'. (1)
 
The Association gradually became established and by the 1860s it was flourishing. The annual meetings were well attended and held at different asylums throughout the British Isles, with regular regional meetings in Scotland and Ireland. A Council body was set up in 1865, quarterly scientific meetings began in 1868 and the Association's journal, The Journal of Mental Science (now the British Journal of Psychiatry), first published in 1854, came to be highly regarded.
 
The Association of Medical Officers of Asylums and Hospitals for the Insane changed its name to the Medico Psychological Association (MPA) in 1865. In 1926 it was granted a Royal Charter and became the Royal Medico Psychological Association (RMPA). In 1971 the RMPA was granted Royal College status and became the Royal College of Psychiatrists.
 
The development of the Association can be traced from the reports of its meetings in the Journal of Mental Science and by the 1870s these reports showed an increasing interest in asylum attendants. In 1870 the Journal printed a letter from 'Asylum Chaplain' (probably the Reverend Henry Hawkins of Colney Hatch, founder of the Mental After Care Association) suggesting systematic training of attendants but there is no record of any immediate response to this (2). Then, at the annual meeting in 1876, Dr Thomas Clouston, the recently appointed Physician Superintendent of the Royal Edinburgh Asylum, spoke on 'The Question of Getting, Training and Retaining the Services of Good Asylum Attendants' (3). The discussion that followed showed that the Association was becoming increasingly aware of the need to recruit 'the best material possible, and to manufacture out of it the best asylum attendants possible' but the participants seemed to consider that training should be provided by the asylums (4). After this meeting, an 'Association or Registry of Attendants Committee' was set up but there is no evidence that it ever reported. Then in 1883, Dr A Campbell Clark spoke on 'The Special Training of Asylum Attendants'. He described in detail the lectures and examinations he had introduced in the Glasgow District Asylum and the 'elevating influences' that had resulted and suggested that the Association should consider his plea for 'a more extended application of the system'.(5)
 
The result was a Handbook and Training of Attendants Committee. This worked quickly and proofs of the 'The Handbook for the Instruction of Attendants on the Insane' were shown to the Associations' quarterly meetings in 1884. The Association agreed that it would be printed and 1000 copies would be distributed. It was first published in 1885 and for the next sixty years and more was known as 'The Red Handbook'
 
Five years elapsed between the publication of the first Handbook and the first examinations. Meeting reports for the late 1880s contain some references to lectures and teaching and in 1889 Dr Campbell Clark spoke again of his own examinations for attendants. Once more the Association appointed a committee, this time 'to inquire into the question of the systematic training of nurses and attendants in asylums for the insane ' (6) which soon recommended that attendants should have two years training, followed by examinations organised by the MPA. The MPA would also issue certificates and keep a register. The Committee's scheme for a nursing proficiency certificate was accepted at the 1890 annual meeting and the first examinations were held the following year. The first Registrar, Dr Beveridge Spence of Lichfield, was appointed in 1892.
 
The examinations rapidly became established. In 1899 Dr Beveridge Spence was elected President of the Association and reviewed what had been achieved in his Presidential Address. Despite 'the new system not in the beginning being enthusiastically welcomed by many of those in charge of asylums, the steady progesss which has been made of late years is a silent but eloquent testimony to the fact that a want has been supplied'. Five or six hundred certificates were being issued every year and candidates from more than a hundred asylums were taking part and the position of asylum nurses had 'unquestionably improved' (7).
 
The Association took its nursing examinations seriously and, despite not having a permanent headquarters or paid staff, retained records of their administration. The general administration of the examinations was the responsibility of the standing Education Committee. This committee was first appointed in 1893 when the MPA was planning its own qualification for doctors but the attendants' examinations quickly became a large part of its work. The Education Committee met three or four times a year, and its reports and the reports of the Association's Council regularly recorded the appointment of other committees to deal with specific training matters.
 

One of the main responsibilities was preparing and publishing the handbook. This was the basic textbook for the examinations and was almost permanently under revision. A revision committee was appointed in 1892 and the second edition appeared in 1893, followed by a new and revised edition in 1898. Frequent revisions and reissues followed, prepared by a succession of Handbook Committees, and when a new (seventh) edition appeared in 1923, it was renamed The Handbook for Mental Nurses. An American edition was considered in 1892 and in 1906 and printing in Dutch, for South Africa, was suggested in 1925. A further revision was begun in 1932 but the eighth edition did not appear until 1954, despite the fact that the Handbook Committee was one of only two of the Association's committees to meet in the early years of the War. Much of the stock of handbooks was destroyed by enemy action in 1941 and a licence for paper to print more copies was refused. The eighth edition came out in 1954 (preparation having been so slow that revisions were needed before it was printed) and the ninth in 1964. Finally, in 1979, nearly 30 years after the RMPA's last nursing examinations, the College's Education Committee decided there would be no further editions. Meanwhile, the Association's Advisory Committee on Mental Nursing had begun considering a handbook for mental deficiency nurses in 1928 and the Manual for Mental Deficiency Nurses known as 'The Green Handbook', was published in 1931. This, too, was soon under revision. Like the Red Handbook, further editions of the Green Handbook were discussed after the examinations had been discontinued and a revision sub-committee was appointed as late as 1965. An addendum to the Handbook for Mental Nurses covering occupational therapy was issued in 1938.

 

The examinations were regulated by the Association's Education Committee, Nursing Committees and various sub-committees. Like the handbooks, the regulations were kept under review and became increasingly comprehensive. New or revised ones were brought into force in every decade, including the 1890s, and modifications were agreed for people in the armed services in 1915 and 1939. They covered all general matters such as eligibility, recognition of training institutions, age at entry, length of training, conditions for holding examinations, payment of examiners, entry on and deletion from the register, disciplinary matters, fees, certificates, badges and medals. Amendments were discussed by committees and were recorded in varying detail in the Education Committee minute books. In the early 20th century the regulations were printed and made available to candidates; in 1911 it was agreed they should be printed in a form suitable for display in nurses' homes; in 1912 they were redrafted and reprinted following suggestions by the Association's solicitor and they were issued as pamphlets in the 1920s and 1930s.
 
The Education Committee minutes occasionally record discussions about applications for exemption from the regulations, about cases of misconduct and about attendants whose certificates were to be forfeit for some reason, such as non payment of examination fees. From time to time, disciplinary sub-committees were appointed and occasionally their reports to Council are in the Council minute books. In 1902, the Copying in Examinations Committee not surprisingly recommended improvements in seating and supervision but, in general few disciplinary incidents are recorded. It is not clear if this is because they did not take place or because they were considered the responsibility of the hospital or asylum concerned.
 
The extension of training from two to three years was first recommended in 1897 and began in 1906. A preliminary examination was introduced in 1908. There was considerable discussion in the 1920s about the length of training and the precise nature of nursing qualifications. The position of nurses with some general training entering mental nurse training and the relative position of asylum and hospital trained nurses became a point of issue with the GNC.
 
At first, the names of successful candidates were printed in the Journal of Mental Science. They were issued with a certificate and entitled to a badge or medal (the terms seem to have been used interchangeably). After 1918, certificates were no longer issued to successful candidates in the preliminary examinations; instead, to avoid them using the certificate to claim full qualifications, their names were entered on a register. Final certificates continued to be issued. The first Nursing Badge Committee was appointed in 1893 and the design they agreed on showed Psyche, respresenting the soul or spirit. In 1903 the Education Committee gave figures for the issue of badges and medals and agreed they would be engraved with the recipient's name instead of their number. In 1909 it was agreed that the words 'with distinction' would be added where appropriate. In 1926 the design was changed when the MPA received its royal charter and Psyche was replaced by the newly acquired coat of arms. At the same time, the addition of an optional ribbon was approved, blue to correspond with the colour in the President of the Association's badge of office. In 1928 an additional badge to be worn on outdoor uniform was suggested. Also in 1928, after much discussion, an honorary nursing medal and certificate was presented to Princess Mary , who had shown a keen interest in nurses' training and welfare.
 
Before the end of the 19th century, the Association considered extending its examinations abroad, first to South Africa in 1892 and then to both British colonies and other overseas countries. It was agreed in 1903 that the MPA certificate would not be promoted in areas where training and examinations were already established. Candidates from South Africa were soon admitted and although independent South African examinations began in 1921 the MPA certificate continued to be recognised there. The Education Committee appointed a sub committee in 1916 to consider the recognition of examinations then being held in southern Australia and this matter became part of the Association's wider discussion on setting up colonial branches - a regular, if infrequent, suggestion that never became a reality. Help with examinations for a mental hospital in Canada was authorised in 1926 and in 1920 Danish trained nurses were recognised. This was possibly the only time European qualifications were recognised although parts of the handbook had been translated into French when the French were developing their own training systems.
 
A separate examination for the nurses of mental defectives was suggested in 1896 and again in 1917 and the first such examination was set in 1918. Further examinations for attendants on mental defectives and a diploma in training medical officers in mental deficiency institutions were discussed in the 1920s and 1930s but were not developed. Much of the administration was covered by the existing regulations and was carried out by the Mental Deficiency Committee, the forerunner of the College's present Faculty for Learning Disability. In 1939, half the committees reporting to Council were concerned with training and examinations, a reflection of the amount of work, all voluntary, that was involved.
 
While the MPA develop its own training, the movement for state registration of nurses also grew. A MPA committee to consider the admission of mental nurses to the British Nurses Association was set up in 1896. When a Parliamentary Select Committee was appointed in 1904 Dr Ernest White of the MPA gave evidence and the MPA President, Dr Outterson Wood, spoke on this in his Presidential Address in 1905. The Select Committee reported in favour of state registration and of recognising the MPA examinations as qualifying for registration. The need for urgent action by the Association to assure proper representation for its nurses was repeatedly stressed and when state registration of nurses became law in 1919 the Parliamentary Committee considered fair representation of mental nurses had been secured. Asylum trained nurses were included in a supplementary part of the register begun by the newly formed General Nursing Council. Nevertheless, in 1916 the Association had passed a resolution that the proposed College of Nursing should be 'watched' so as to safeguard the position of mental nurses and in 1920, the Association, not wishing 'to remain passive or inarticulate when danger appeared' appointed a committee to 'watch' the GNC (8).
 
Soon the position of mental nurses was causing concern and meetings with the GNC and discussions on nurses' registration and the position of the Association's examinations were held from the 1920s onwards. The RMPA did not claim to be a registration authority but wished to remain an examining body; nevertheless adjectives such as 'inflexible' and 'unsatisfactory' were at first used to describe these meetings, although by 1928 'a general feeling of goodwill seemed to prevail' (9).
 
The Association tried hard to retain its own examinations despite a 'revolutionary' resolution submitted by the Scottish Division in 1937 suggesting that they should be abandoned in favour of the GNCs. However in 1945 the Athlone Committee recommended they should end, the Council reported that relations with the GNC were improving and an agreement was reached in 1946. The RMPA received letters of complaint and regret and the related loss of revenue from fees and the handbook was criticised but the last examinations were held in 1951.
 
In 1952, the Registrar, Dr Iveson Russell of York, informed the Council that a total of 50,021 mental nursing and 5,256 mental deficiency nursing certificates had been issued and there had been no year since 1891 when the examinations had not been held. He continued 'the Association could look back on this work with some pride. The services involved more than the organisation of examinations at a time when no other branch of nursing had any other national standard or qualification. It standardised the syllabus of training in all the mental hospitals and mental deficiency hospitals of the country, and was almost entirely responsible for the training of mental nurses before the passing of the Nurses' Registration Act in 1919' (10).
 
For a while the Association advised the GNC about the syllabus for both the mental nursing and the mental deficiency nursing examinations, especially on the inclusion of psychology. In 1954 a committee was appointed to consider the shortage of mental nurses and the possibility of starting RMPA examinations again. It produced a report on the shortage of mental nurses and it seems that a new examination was planned.
 
For a while, too, the RMPA and GNC needed to work together on disciplinary matters. An RMPA nurse, if struck off the GNC register, could still in theory use the title 'nurse' so in 1962 it was agreed the GNC would take over all disciplinary matters and put in place unifying procedures.
 
The Association also briefly ran an occupational therapy examination. Planning began in the 1930s and there were five successful candidates in 1939. Possibly the war prevented this examination developing. Although the Association put its view to the post war Rushcliffe Committee that occupational therapy was a nursing duty and tried to restart this examination, negotiations for abandoning had begun by 1946 and it was abolished in 1947.
 
In addition to the badges available to successful candidates, two medals were also awarded. The Campbell Clark medal was instituted in 1933 in memory of Dr Campbell Clark. It was awarded each year in May and November to the candidate with the highest marks nationwide in the final mental nursing examination. It was discontinued in 1951 as the Association's examinations came to an end.
 
The Eleanor Finegan medal was instituted by Dr Arthur Finegan in memory of his wife and was originally awarded to the nurse, male or female, at the Mullingar District Asylum, West Meath, Ireland, who had the highest examination marks. This was later changed so that the Prize (worth £5 per annum) could be awarded to the nurse with the highest mark in the examination wherever it was held and this too was discontinued in 1951.
 
In addition to summarising the history of the nursing examinations run by the (Royal) Medico Psychological Association, the purpose of this paper is to draw attention to the sources relating to these examinations that survive at the Royal College of Psychiatrists, the successor of the RMPA. The College did not have its own headquarters until it moved to Belgrave Square in 1974 and its predecessor bodies had rented a series of rooms with various other medical organisations. Consequently there was no systematic provision for archive keeping and the surviving records are small in comparison with the age of the organisation. Correspondence and financial papers are the main gaps in the College archives but mental nursing is well represented among what has survived.
 

The College holds a complete set of the Journal of Mental Science, now the British Journal of Psychiatry, and an almost complete set of its associated Year Books. The Education Committee presented a report to the annual meetings. Additionally, educational matters were sometimes referred to at the quarterly and regional meetings. There are no manuscript minutes of these meetings. Minutes of annual, quarterly and regional meetings are printed in the Journal or in the related Year Books and have been abstracted onto an in house database (the Meetings Database). The names of successful examination candidates were included in the Journal until the 1930s but they are listed by hospital not alphabetically.

 

The archives include complete set of Education Committee minutes from 1893 onwards. They cover all aspects of the administration of the nursing examinations and a prime source for the history of mental nurse training. It will be clear from the history outlined above that the Association's reaction to any suggestion or problem was to appoint a committee. Many of these special and sub-committees were set up to consider matters relating to nurse training and examinations and reported to Education Committee. Their reports are sometimes inserted in the minute books.
 
Other insertions include some of the Education Committee's reports to annual and Council meetings and a few examination question papers, syllabi, Registrar's reports and letters.
 
The Education Committee reported to the College Council. This met three or four times a year (except in wartime) and the Council minutes are complete for the period of the nursing examinations. These too have been abstracted onto the Meetings Database. The Council minute books also have some insertions, for example Education Committee reports and reports from some other relevant special and sub-committees.
 
There is one folder of Handbook Committee minutes and reports to Council, 1930s to 1950s, with some related correspondence.
 
The Parliamentary Committee minutes also include relevant information as nurses' registration, pensions, hours of duty and other matters relating to working conditions were at times parliamentary business. Legislation and Parliamentary Committees were among the earliest to be set up by the Association (the Parliamentary Committee celebrated its centenary in 1954) but unfortunately the earliest surviving Parliamentary Committee minute book dates only from 1906.
 
There are also registers of successful candidates for the mental nursing and mental deficiency nursing preliminary and final examinations, 1891 to 1951. The sequence is complete (25 volumes) but is limited as an historical source as the volumes include only the candidates names and numbers and the names of the hospitals where they took their examinations. Finding information can be difficult as, although each volume is indexed, there is no general index or register of successful candidates. Until the late 1980s the College received enquiries from hospitals asking for details of the RMPA nursing certificates and for confirmation that the qualifications potential employees were claiming were officially recognised. Now the enquiries come from family historians.
 
There is also a single volume containing the names of the five successful candidates for the short-lived examination in occupational therapy, 1939.
 
There are printed question papers (but not written examination scripts) for the Mental Nursing and Mental Deficiency Nursing Preliminary and Final Examinations, 1928 - 1951, regulations from the 1920s and 1930s and syllabi, 1927 and 1932. Earlier question papers may be found in the Journal and inserted into Education Committee minute books.
 
There is also a small collection of nursing medals, badges and certificates. A few of these are identified and from time to time others are sent to the College.
There is very little correspondence. There is a small folder of letters, 1926-9 on relations with the GNC and the Scottish GNC, mainly the future of the examinations, some more similar correspondence and notes from 1946 -51 and correspondence, notes and the RMPA report on the shortage of mental nurses, 1954
The series of handbooks includes both the red (mental nursing) handbook, excluding the third and sixth editions, and the first edition of the green (mental deficiency nursing) handbook.
 
Minute books and correspondence of the Association's Scottish Division, containing references to training and examinations, are held in Edinburgh University Library.
The College archives are open to serious researchers and as the College is a membership organisation, there is a £10 day access charge. Please contact the archivist if you would like to use the archives or if you would like any further information.
 
  1. Royal College of Psychiatrists' archives: minute book 1 (2)
  2. Journal of Mental Science, volume xvi, page 310, 1870 (3)
  3. Journal of Mental Science, volume xxii, page 381, 1876 (4)
  4. Journal of Mental Science, volume xxii, page 499, 1876 (5)
  5. 'The Special Training of Asylum Attendants' Journal of Mental Science, volume xxix, page 459, 1876 (6)
  6. Journal of Mental Science, volume xxxv, page 450, 1889 (7)
  7. Journal of Mental Science, volume xlv, page 635, 1899 (8)
  8. Royal College of Psychiatrists' Archives: Council minute book, 1914-23 (9)
  9. Royal college of Psychiatrists' Archives: Nursing Collection: correspondence with GNC. (10)
  10. Royal College of Psychiatrists' Archives: Council minute book, 1949-54

 

Margaret Harcourt Williams
College Archivist
December 2001