The history of nursing, as Carol Helmstadter and Judith Godden point out in their preface, has followed several different narrative lines, the first and most persistent one being that the transformation of nurses from “callous, dirty and immoral” to “idealistic and professional” was the result of the influence of one woman, Florence Nightingale (xi). This narrative has not held sway for many years, as the authors of Nursing before Nightingale acknowledge. Their objective is to “go beyond traditional and revisionist interpretations of the older ‘pre-Nightingale’ nurses” to look at nursing “in the context of the pre-industrial nature of the early nineteenth-century workforce and the rough realities of that society” (xiii). The overall argument goes beyond the issues of early hospitals' preindustrial organization—or lack thereof—and far beyond nursing before Nightingale, who figures prominently in this history. The larger argument is about advances in medical practice that produced a demand for more skilled nursing and about the leadership of Protestant nursing sisterhoods in reforming hospital nursing, implementing reforms that did indeed begin before Florence Nightingale became a household name in Britain and beyond and that continued long after she inspired a nation to be concerned about nursing care.

Helmstadter and Godden begin by presenting a detailed picture of the state of hospitals, their patients, and their employees in the early years of the nineteenth century. In this section of the book, there is a particularly skillful integration of the social and cultural history of the working class, the history of nursing, and insights and information gleaned from careful archival research. In this context, the specificity of reports of often riotous behavior on the part of patients, nurses, and other hospital employees, as recorded in hospital records, convincingly demonstrates that life in hospitals did indeed reflect the “rough realities” of working-class life (xiii). The menials who cared for the sick poor and who followed the imprecise “pre-industrial sense of time” (34) were unable to adjust to the growing demands of increasingly scientific and sophisticated medical practice, leading to various attempts to develop workable new systems of nursing. The most influential and lasting of these were the “doctor-driven” (47) ward system and the training system developed by the nursing sisterhoods. While analyzing the pros and cons of both approaches, Helmstadter and Godden credit the sisterhoods with introducing the most radical and important reforms in hospital nursing. Both systems strove to attract a more respectable class of women, an innovation that was in part dependent on providing acceptable housing for nurses.

It was the sisterhoods, and in particular St. John's House, that provided the essential impetus to producing more professionalized, reliable, and efficient nursing care in hospitals that was also a systemized and comprehensive form of nursing education. The contracts to provide the nursing services in several London teaching hospitals enabled sisterhoods to provide probationary nurses with both education and practical experience in the care of acute patients. In the sisterhoods' success were the seeds of their demise, however; their more skilled nursing care, Helmstadter and Godden posit, made it possible for doctors to treat more patients more effectively. The number of patient beds increased and that in turn increased the costs of nursing services. The sisterhoods, which had always subsidized these costs as “a charitable contribution . . . to the sick poor” (173), finally could not sustain themselves financially. In attempts to renegotiate nursing service contracts, hospital administrators were unwilling to meet the financial demands of the sisterhoods' nursing and, more crucially in the view of Helmstadter and Godden, unwilling to grant the sisterhoods the authority to control the nurses and the services they provided.

While the overall argument about the influence of advances in medical practice and the work of nursing sisterhoods is not new, the careful and detailed presentation of that argument makes this treatment of an old story particularly valuable. This contextualization of early nursing practice and hospital organization within the history of the culture at large is the greatest strength of this fine treatment of nursing history. Helmstadter and Godden's scholarship, moreover, is comprehensive and meticulous, their archival research exhaustive, covering the collections of more than twenty hospitals and nursing institutions. Their revision of the history of nursing is in many ways still an affirmation of the overpowering presence of Nightingale, who dominates the two chapters on nursing in the Crimean War and whose influence over public and professional perceptions of nursing and nurses is apparent throughout. The book ends with a detailed analysis of why the Nightingale School was ultimately able “to emerge as the front runner in nursing reform” (193). Rather than a history of nursing before Nightingale, this is a history running parallel to Nightingale's story—a history that demonstrates that it was in fact the sisterhoods, not the Nightingale School, that developed an effective formal system of training and nursing education. That the sisterhoods “failed to establish their system as the model for the new nurse,” Helmstadter and Godden argue, “was in large part because they were in advance of their time” (189). The sisterhoods nevertheless “left a significant legacy”—the development of professionalism in nursing and, most crucially, “the recognition of nursing as a specific body of knowledge” (188, 189).