5. Washing, how to be done? Rule to compel the Nurses toput it out.5.Washing.—Except in war-emergencies, this must not be suffered to be done by the Nurses, they must be compelled to put it out. I would not trouble the Authorities about this; the Nurses can afford it, and the more things are simplified the better. In out-of-the-way districts, the Matron might arrange with a laundress, the Nurses making a fair payment. In war-emergencies, if possible, provide a strong washerwoman, but this would have to be settled each case on its merits. Except in emergencies they must not wash; it takes up far too much time; it takes up strength which is wanted for other things; and washing and drying either in wards or nurses’ rooms is unhealthy and objectionable. There must be a ruleas to this: some worthy souls would scrub at every rag, rather than pay a few pence weekly. The Nurse ought, however, to be compelled to have certain changes of linen weekly, which some will not, if they pay for it themselves.6. Cleaning their own Rooms. No Orderly, on any pretence, must enter a Nurse’s Room. Scrubbing the only thing the Matron may arrange for a Soldier’s Wife to do. Nurse must do nothing of her own in Ward, or Ward-kitchen, or Orderlies’ Kitchen.6.Cleaning their own rooms.—I well foresee sundry difficulties in the little rooms at the entrance of their wards, where I hope it will be managed to quarter the Nurses. But there is no other way of fairly and really working a ward; and I trust this plan will receive a fair trial. For efficiency, also for comfort, it is most objectionable to make the Nurse sleep at a distance from the patients. This is one of the points on which theories, and the practical working of things, are very divergent. It is an excellent thing when the Head-Nurse’s room opens into the ward and when part of the upper part is of glass, with a thick curtain, so that she can see into the ward, without being seen. Let each Head-Nurse have a small room, with a window opening into external air, with a curtain making an alcove, behind which there should be a small iron bedstead, with good bedding, and a washing table; and in the foreground a table, a small one for meals, a chest of drawers, and a comfortable arm-chair, two chairs, and I should add a sofa. Each room should have a few shelves on the wall, and a large cupboard or small closet with broad shelves, and space at the bottom to stow away the Nurse’s box. Simplification and avoiding all trouble which can be spared to the Departments are very important. I would not therefore insist upon a little kitchen for the Nurses, nor upon a very capital arrangement in some of the Sisters’ rooms in Guy’s Hospital, where, behind a decent little doorinthe sitting-room, there is a sink, with water laid on, a little safe for meat,&c., at top, and a complete little apparatus of the very few utensils required for cooking one woman’s meals; so that a Nurse can cook and wash-up, in her own room, without carrying things out of it. This is much better than a kitchen, if the Nurse is to cook her own meals; but, as above stated, I would rather she did not. One room, with a curtain making an alcove, is much better than two. The Queen is saved fuel; the Nurse is saved cleaning two rooms; and if fuel is only issued for one, she sleeps in a warm room, instead of one where there never is a fire, and where her things get damp and spoiled. Often, where Head-nurses have two rooms, one is built without a fire-place. Condenseand simplify all things—one great object is to form a body of useful hard-working women, of simple self-helping habits. Two Nurses’ rooms should be together, but separate. Sudden illness might occur, and the two women should be at each other’s summons. The Quartermaster-Generalmustgrant acabinetbetween the two: this ismust, notmay. The Superintendent-General must see to this herself, at first at all events: thereisa singular obtuseness in the small officials, by whom these things are managed: if not overlooked, they will be sure to put the construction in a particularly awkward, exposed place. These things do enter into an Englishwoman’s daily comfort or misery—it is worth arranging them decently in the first instance.Now as to the cleaning of these rooms. Head Nurses generally are far too much disposed to make servants of their nurses; put orderlies for nurses, and this objectionable tendency would be a hundred-fold more objectionable. The Matron must make it an absolute rule, that the only thing an orderly does for a nurse is to carry her box in and out on the two grand occasions of her entering and leaving the Hospital. The one thing which in a Civil Hospital, an Assistant Nurse should be allowed to do for the Head Nurse, is the cleaning her fire-place, a thing done in a few minutes, and with satisfaction, by women who have done it all their lives; but a dirty tedious messing business to those who have not. But never mind: the orderly must never enter the Nurse’s room: she must do it, and learn to do it. The prosaic little business of black-lead, ashes, and mess lying on the threshold of the work will do good rather than harm. And even black-lead is unnecessary, as a varnish now obtainable looks better. The orderly must never enter the Nurse’s room—asine quâ non. The Nurses should have, at their choice, a carpet, not nailed down, or none. In either case the room will require scrubbing, once a week if no carpet, (which is best and cleanest in Hospital life), seldomer, if carpet. Now the Nurses should not be required to scrub their own rooms—it is useless waste of strength—it makes their hands coarse and hard, and less able to attend to the delicate manipulation which they may be called upon to execute—and with all thenursing properwhich ought to fall upon them, and not upon the orderlies, their time can be better occupied than in cleaningtheir own rooms. Also, while trying to keep clear, on the one hand, of the tribe of “fine ladies,” it will be possible, on the other, if such menial offices are to be performed, to fall into the opposite mistake and to fail in obtaining the class of women desirable to fill such important trusts. Let the Matron consent to a charwoman, soldier’s wife, or some one person named and defined, and found, to be paid by the Head Nurse, to come for the two hours, which, at furthest, this business will take. It would be well worth while for the Matron to look out and provide two or three strong women to do this, by fixed rotation—each Nurse making a fair payment—and to ascertain that they are in and out of the Hospital by a particular hour, so as to prevent these external persons doing other things than scrubbing. But do not trouble the Departments as to this—the more things are simplified, and the fewer expenses are in connection with the Nurses, by far the better.Take the trouble to see that a tidy useful fire-place is in each Nurse’s one room. Some fire-places will consume thrice the fuel of one which can do ten times more work. A compact useful little fire-place, to burn as little fuel, and do as much business (in a very small way) as possible, is a thing of daily use, economy, and comfort.The nurse should not do anything of her own in the ward, or the ward or orderlies’ scullery, if there is such a place. This is a matter requiring some decision.7. In each Ward to be Closet, with Shelves, Table with Drawers, Nurse with Keys. Nothing to be kept in Nurse’s Room. Linen, Dressings, Stimulants to be kept in Ward Closets.7. Let there be in each ward a closet, or, better still, a dresser,[8]with broad shelves, and a large table with large drawers, of which closet or dresser, and drawers, the nurse has the sole keys. Let the articles of linen which are kept in the ward be there; also the bandages, lint, old linen, oilsilk, ointments,&c.,&c., which should always be, some at hand, some in reserve; also the wine and brandy ordered for the men. Let the nurse never be allowed to deposit Hospital property in her room, which, if there is no place for it, shemustdo, and it is much better she should not.8. Matrons 200l.per annum, Quarters, and a Maid. A woman for the Linen, ranking and paid as a Nurse, but never entering the wards.8. With regard to the Matrons, though as Locke says of tutors, there are all kinds of persons to be found, it is certain the right persons are not always found; and these officers will take time to find, at the outset especially. Let them be (if it be possible) of the middle class; if it be possible, middle aged, active women, widows of officers or army surgeons. A vast deal of struggle is ever going on in professional life; a vast deal of silent, decorous misery ever follows on the premature deaths, the compelled early retirements, the sundry chances and changes which ever abound in the army of England. So far as it goes, andcæteris paribus, it would be right, just, and expedient to give a preference for these matronships to widows of officers and army surgeons. Try to secure thorough principle, sense, activity, and steady discreet ways; never mind a little vulgarity of manner; that the different orders should have their indefinable perpetual distinctions of manner as of other things, is perhaps for a long time to come in the essence of things. Two or three women of the stamp of the Matrons of a few of our Civil Hospitals would be very valuable. If the Matron do not get tired of what, unless one keeps one’s secret thoughts fixed on the meaning and the end of all things, is coarse, thankless, up-hill work enough—she will in the course of years accomplish great good. But she must have principle, sense, heart, and a firm cheerful mind. She must be not under thirty and, if possible, not over forty, on appointment. Should her being without children be made asine quâ non? Children—poor little things—are wanted nowhere in the way of business, but do not be too strict about this: they are sometimes pledges to other things than fortune—thoughts, anxieties, and labours for them, concentrate and steady a mother’s heart—there will be fewer adventurers. Maternalnursesmust upon the whole be discouraged, because upon the whole the disadvantages seem to overweigh the advantages.[9]But the Matron’s office and duties are different; she is not fixed to a great ward of patients; and her having children should not be a bar, especially if theydid not live with her. Young and grown-up daughters are much in a Matron’s way; sons matter much less.The greatest Civil Hospital gives its Matron 200l.and ahouse, the other great Hospitals, 150l., and ahouse. The London Hospital gives 150l., and a couple of good well-furnished rooms, and a servant. Ahouseis an impediment to a Matron’s duty. She is seen arriving in the wards, and she is more or less hindered in entering them. From her rooms she issues and re-issues, unexpectedly, and much more efficiently. 200l.and quarters is not at all too much.The Matron must be responsible for the storing, mending, and distribution of the linen, and for returning to the laundry any linen not properly washed or dried. Linen ought never to be dried in the wards, a process both inconvenient and unwholesome. The Matron ought to have a steady, respectable woman, certainly not below the rank and pay of a nurse, to be responsible to, and under her, for the linen, otherwise the proper care of the linen will take up far too much of her time. This is important. If, however, a Nurse should be thus set aside for the Laundry, she must not be allowed to enter the wards; otherwise she will unconsciously become a gossip and mischief-maker. I would term her “Linen Nurse,” not Assistant. The Matron should also have a steady, properly paid servant. A Matron of the proper sort has quite other things to do at a leisure moment, than to keep her wardrobe in order. She must have a servant; but it seems to be advisable to simplify things, and condense payments as much as possible; and I would rather consider this in the salary, and let the Matron find and pay her own servant. Try to have the servant’s room near the Matron’s. These minutiæ, once provided for, enter much into the daily working and comfort of things.The dress of the Matrons is a difficult thing to settle. Sometimes a Matron is afflicted with a taste for either gorgeous or elegant apparel, which the Nurses are invariably proud of, admire and humbly emulate. This sort of thing would be really out ofplace in a Military Hospital, and would moreover sadly discompose the Nurses with their plain caps and gowns. How would it be to allow the Matrons the choice between a Regulation dress and a plain black or brown silk gown?It will take much thought to decide whether the Matrons should all be paid alike, or whether climate and size of Hospital enter into this. On the one hand they undertake a service, of which almost the first regulation very properly is, that they undertake to go to all parts of the world as soon as sent; on the other hand, certainly some climates wear health and life much quicker than at home.The Matrons out of the three kingdoms have increased responsibility, and can do more mischief, if incompetent or untrustworthy.If the Matron has increased pay abroad, it would not do not to augment that of the Nurses. This is an important matter; and as it is on all accounts necessary that Matrons and Nurses should on their engagement thoroughly understand the nature of the service they undertake and, of course, a serious part of the service is that it involves sudden and long removals, it would be necessary to define upon what terms they go abroad. Yet it never would do, for reasons which will readily be perceived, to make the foreign stations objects of desire to Matrons and Nurses. These stations will always be so far the most anxious, that they will always be the most removed from the Superintendent-General’s inspection and immediate rectification of anything that goes wrong. They will also be, in various ways, the most trying to Nurses. The rules once settled, every Matron and Nurse refusing to go abroad when ordered, ought at once to be discharged, and to forfeit all re-admittance into the service and all pensions. On the whole, I think the Matrons should all be paid alike. But inasmuch as foreign service necessitates more wear and tear to the constitution, one year should count as equal to two years of service for pension, in case of disability. The same should be made applicable to the Nurses. As the advantage is distant, it would, in a great measure, do away with any desire for foreign service.Volunteering for foreign or war-service must be the exception—careful selection the rule. The “adventurers” will be generally ready to volunteer, and it would be too much to hope that we shall always, perhaps ever, be entirely free from that tribe; the most we can hope is soon to discover and get rid of them. Foreign stations will never do for an untried Matron or Nurse. At the same time it is most desirable not to change the Executive officers of any Hospital more than can be avoided.But let there not be too many rules at first; see how things work, and take one step at a time.The selection of exclusively middle-class Matrons seems to be important.[10]Their order will disarm one source of opposition and jealousy; plenty more will remain, inseparable from the work; but it is good to get this out of the way.The name of Matron is the same as in Civil Hospitals. In many respects the office and duties are different:e. g., the Matron in Military Hospitals must exercise a far more constant supervision in the wards. But this will require great discretion on her part. It is the practice of most Civil Hospitals for the Matron never to enter the wards till the Nurse’s dressings are over. It would be advantageous to modify this. But, at the same time, the Matron must understand Hospital Nursing, or she may make very serious mistakes in either reprimanding or directing the Nurse as to technical matters. She must be a person who knows herself what she has to see that others know; or she will get herself, with or without the Nurse, into very injurious errors. There is much in a name; and, in some respects, that of Superintendent would better denote her office, as regards the Nurses, would add to her authority, which is desirable, and would point her out as acting under the Superintendent-General.Incorporate among the Nurses whatever women of the higher orders may be admitted into the Service at first. If inefficient and unfit they are far better altogether eliminated. If thoroughly efficient as Ward Nurses, if thoroughly obedient and respectful to the Matron, if they have sense and heart to gradually leaven, not coldly withdraw from occasional companionship with the other Nurses, they will, in the course oftime, effect quietly a great deal of good.There should be some Rule of this kind—Any Matron or Nurse who may receive permission to serve Her Majesty without pay shall be, in all respects, bound by and amenable to the Regulations on pain of dismissal from the service, without permission of re-entering it.If this cannot be done, money can easily be returned in one shape or other; but it would have a good moral effect on the Nurses to allow of the admixture of unpaid Nurses, provided they are strictly bound by the same Regulations, and distinguished by no sort of peculiar designation.The Surgeons will dislike these unpaid Nurses; but, in the long run a firm, discreet woman,who is an efficient Nurse, can get on with any Surgeonwho has his sick at heart. The Matron also will not at all like them, at first, but will find that she can rely upon them and that they quietly and effectually help her with the other Nurses: and, if she has her heart in her work, she will end by being just, though, perhaps, always a little extra strict with and jealous of them. The other Nurses will have, at the first, a strong little touch of republicanism towards them, which will gradually wear off, and, with God’s help, a higher and truer moral tone, and a simpler and more useful kind of habits among them will prevail, than would otherwise be the case. As for the patients, with all their faults, trust them—trust the English soldier, and the peasantry from which he springs. What these poor fellows are we know, and need not discuss. They are worth suffering a good deal for; please God in the long run good will be done. If only we can keep clear of the false, pernicious, and derogatory system of puffery and fuss which others, for their own purposes, and from vague, silly good-feeling have wound around this work—a work essentially unpopular the moment we come to details! We have learnt what reality is and what its presence or absence in this business imports. As for the many and great other difficulties of the work, they must be appreciated, they need not be dreaded. The purpose is a good and noble one, and God grant it success! All we have to do is, to do our utmost, and leave the event to Him.9. Nurses—begin with few at first.9. As for the Nurses the material must be formed. If a few respectable soldiers’ widows, including, and all the better, non-commissioned officers’ widows, could be found,cæteris paribus, a preference should be given to widows of the Service.Except in emergencies Nurses should not be taken under thirty, or above forty[11]years of age. These women are Head Nurses. Most of the Civil Hospitals take no Head Nurse after forty.One caution in engaging Nurses is perhaps not sufficiently attended to. Certificates, without personal inquiry and answers to distinct questions, are not worth the paper on which they are written.As to engaging any Nurses out of the great Hospitals, for sundry reasons, this should be done as little as may be.Let us begin, for the sake of God and this His work, with few women. Extension is easy—to occupy too much ground at first would be, I do in my conscience believe, an irretrievable mistake.No unnecessary Nurses should be suffered in Hospital; and no Nurse in charge of wards should be required to do needlework for the Hospital. There should be no superfluous hands; and the less a Nurse enters another’s ward the better.In case of suspension of a Nurse for misconduct, temporary assistance must, however, be obtained; and this might be either appointing another Nurse, to do, for the time, such duty in the suspended ward as she could do in addition to her own, or putting in a temporary substitute.All such dislocation of the Service, necessary and useful for emergencies and holidays, should, nevertheless, be made to take place as seldom as may be.No Nurse, during her suspension, should be allowed to enter any ward of the hospital.Any Nurse asking or accepting a present, whether in money or in kind, from any patient, or friend of any patient, whether during his illness or after his death, recovery, or departure, must be at once suspended from duty, her pay immediately cease, and the Superintendent-General be apprised of it, who, if satisfied of the truth of the charge, should immediately dismiss her.Two hours daily for exercise or recreation should be allotted to the Nurses, during which two hours they are to be considered relieved of the responsibility of their wards. But I would not be too absolute in requiring them to go out: sometimes to lie down or sit still for an hour or two will do more good than a walk. Give them two hours for optional exercise. Head-Nurses cannot have more of fixed leisure. They must get time for private occupation as they can: very often not at all; and no Nurse fit for her place will, of course, in emergent states of her ward, leave it. Also the Matron must not worry herself or them, if an anxious Nurse sits up part of a night or a whole night with bad cases.To a certain degree the Matron will find it better to allow a little liberty and choice, in the matter of times and hours, (always excepting after proper hours,i. e., after dark) to the Nurses, who are Head-Nurses, than to attempt making them mere machines. An uniform system, as far as possible, and a little range to each, will answer best. But do not hurry the uniform system too much; take time: this is very important.The Nurse should, every morning, at an hour to be fixed by the Chaplain or Matron, read aloud in the ward, the Confession, the Lord’s Prayer, the Collect for the Week, the Collect for Grace, and the Benediction; and every evening, at an hour to be fixed by the Chaplain or Matron, she should read aloud in the ward the Confession, the Lord’s Prayer, the Thanksgiving, the Collect for Aid, and the Benediction.[12]This would Christianize things, instead of heathenizing them; and I believe not a soldier would dream that his conscience was injured by it. The Roman Catholics and Presbyterians might be allowed quite to refrain, if they chose, which they would not. It would be necessary for the Chaplain-General to approve of and direct in this, and best to wait a year or two before beginning it.The prayers should be very short, the whole not more than five or six minutes each time, and the Nurse should read them, the men joining at the proper times.In some Civil Hospitals the prayers are far too long and are gabbled over by some patient, perhaps the worst character and the best scholar in the ward, or are stumbled through by some little boy, upon whom the others cast the distasteful office, with circumstances of irreverence, partly unintentional and partly shocking. AtSt.Bartholomew’s Hospital the very short morning and the very short evening prayers are printed clearly on each side of a card, which is affixed to each bed; and each morning and evening the Head-Nurse reads them aloud: the difference is very great.10. Have the Diets sent hot and ready-divided from the Kitchen.10. The Colney-Hatch Lunatic Asylum has a diet system worth inquiring into; nothing is fetched by the Nurse, the Medical Officer writes the diets on a large slate which is ready for him outside the ward.The great advantage of this seems to be, that the Nurse’s time is set free from a good deal of arithmetic and some writing; also that each man’s portion is served himhotfrom the kitchen, not cut up laboriously by the Nurse. In most Hospitals the Nurse cuts and divides the diets; in the London Hospital she moreover weighs them. All this takes a great deal of time. If the patients can get the divided portionshotfrom the kitchen, it is far preferable.AtSt.George’s Hospital the portions are sent hot and divided from the kitchen.11. The less any Patient is made into an Orderly by the Surgeon the better. The Nurse should have Regulations to invoke to allow her to do her duty.11. It should be distinctly settled by whom poulticing, fomenting, and all minor dressings, applying leeches and blisters, and giving enemas,[13]are to be done.It would be advisable to consider whether the Nurse ought not to instruct the Orderlies in some things. This, if it did not clash with Orderlies’ Rules, would make these men, especially those ordered for foreign service, much more useful than they are now, without such teaching.It will, however, be essential that there should be no clashing between the Nurses’ Regulations and those already or to be issued to the Orderlies. And for this, among other reasons, it is essential to establish a direct channel of communication between the Director-General and Superintendent-General of Nurses.Ward Medical Officer to give Directions to Nurse.I think, upon the whole and with reference to preventing, as far as rules can do it, the obstruction of the Nurse’s duty, by adverse or inexperienced Medical Officers giving orders to Ward or Assistant Ward-Master, Orderlies, or patients, instead of to her, that it is better to charge him to give the Nurse his orders as to the sick.All the above-mentioned things should be done by the Nurse,i. e., by her habitually and as a rule; occasionally letting an orderly do them, under her own eye, in order that he may learn, as well by doing them sometimes himself as by often seeing her.The reasons why all these things must be clearly settled beforehand are these:—I. Adverse Medical Officers will make all use of counter-regulations.II. Medical Officers who give fair play will find it impossible to settle the matter, if, on ordering,e. g., leeches, the Orderly shows Rule so and so by which he does it, and the Nurse Rule so and so by which she does it. The existence of the old regulations and the arrival of the new ones, about the Medical Staff Orderlies, were made great use of against our work, by some of the Medical Officers, after the heavy pressure of the war was over. So, at Scutari, a Principal Medical Officer took away and would not restore the practice of the nurses giving medicines, in which he was borne out by an existing rule. Contradictory rules are miserable things.Unless the Matron’s authority is supported by the PrincipalMedical Officer the Patients always suffer. The Nurse is the only proper person to be responsible for the directions of the Medical Officers being carried out in a General Hospital.III. It will enable the Matron to stop all nonsensical prudery, on the part of the nurses, and to require that they should do what they undertake to do, and not pass off to an Orderly, still less to a patient, the duties they should discharge themselves.As a general rule there is a good deal of this false modesty on the part of Nurses, especially of Head Nurses. In individual cases it is a serious thing to shake even false ideas of decorum: in laying down general Rules it is the more important to lay down as duties what are such. Suppose an application of what the French call “la petite chirurgie” ordered. The Head Nurse “never dreams of doing such things.” The Nurse, following her superior’s false shame of duty, transfers the business to an ignorant patient. In some cases great harm has arisen thereby to the Patient. In other cases, but not the majority, after such an order given, the Head Nurse goes quietly to the bed, draws the curtain round it, and makes the application herself—saying “she always did that herself, as it was a business requiring care, as the patient was often disposed to resist, and as she was thus certain that it was properly and effectively done.” I have always admired and respected such women; but they are not the majority. Very often patients are allowed or left to do things for themselves, which they cannot do properly, or when they ought not to be trusted to inflict the pain on themselves which doing things properly often causes.The practice of allowing some particular patient to become a sort of half orderly in the ward, letting him always attend some particular case, or give general help in severe cases, is most reprehensible. It is never allowed, whether in Civil or in Military Hospitals, without very bad consequences to the discipline of the ward. Where extra help, in lifting,&c., is required, let the Nurse require the most convalescent of the patients to help, but let her carefully refrain from selecting any patient or allowing any patient to put himself forward, as a regular help or quasi-Orderly. As an almost invariable rule it will be found that the less patients do for each other the better for themselves, and for the discipline and the good feeling ofthe ward. Let them be made useful in the wards, as far as possible, in such lighter cleaning,&c., as a patient can properly do (here, again, discretion is required, or a lazy Orderly will lay undue burdens on a willing patient); but the less they do for each other undoubtedly the better for all parties. I would not, however, expressly exempt the patients from being made useful in nursing the sick. A lazy or ill-conditioned patient might make it a handle to refuse to do or grumble at doing things which he ought to do, such as (a thing frequently required) giving and emptying a bed-pan to an ordinary patient who cannot leave his bed, while the Nurse and Orderlies are doing other things in the ward; assisting to move a helpless patient, if all the Orderlies are not at hand; sometimes watching or attending for an hour or so a critical case,&c.,&c.,&c.What the Superintendent-General and all Superintendents must be especially vigilant against is selecting any particular patient or allowing a willing patient constantly or often to do these things, and to become a quasi-Orderly to the ward or to any patient in it.Assistant-Surgeons, partly from inexperience and partly from spite, sometimes make this sort of quasi-Orderly of a patient. The Nurse should have the power of respectfully saying, in such a case, “The Regulations order me to do so and so, sir: I beg you to let me do my duty.”It is an important and should be, if possible, an invariable rule that no discharged patient is ever to enter any ward. Soldiers are, in many respects, on a different footing, as to each other, from Civil patients. The above provision is perhaps rendered thereby (not the less, but) the more important for the good order of the ward. Still this, desirable in (and the rule in several) Civil Hospitals, might be considered by Military as well as Medical Officers to interfere too much with the feeling of comradeship which, in its measure, is so essential a part of the soldier’s very peculiar condition. The following rules however might, at all events, be carried out. Some of them are actually in the “Hospital Regulations.”As quietness is indispensable in Hospitals, every duty should be performed with the least possible noise, more especially at night. Every patient must be in bed by 8 o’clock in winter, and 9 in summer; and no conversation must be permitted afterthat time. Patients should be made useful in the wards, as far as possible; but should fetch nothing into them. And no discharged patient should be permitted to enter any ward, except in the fixed visiting hours. The Governor, where there is a Governor, or the Principal Medical Officer, will fix the visiting hours; which shall not be more than two hours during each of three days of the week. [Take proper advice as to whether this maximum is too short. It is fully enough for Civil Hospitals, but Military Hospitals are in sundry respects essentially different.]In the discipline of all Military Hospitals, besides the prohibition of all swearing and foul language included in the Articles of War, is included the non-admission, or if by oversight admitted among visitors, the immediate expulsion of all disorderly persons. (Query—whether not to specify prostitutes.)I very much wish that Hospital Sentries in General Hospitals might keep out all visitors, except in the fixed visiting hours. And I very much wish that a stringent rule were made as to female visitors, both in Regimental and in General Hospitals. Proper Military as well as Medical advice should be taken on this point. It might not do to exclude them altogether; and, if soldiers’ wives come, it might be better to admit also all respectable-looking women, for it would be useless attempting defining as to sisters, aunts, friends,&c.,&c.; though, except in the case of dying patients, all women, except their wives and mothers, are better away. I do not know what amount of strictness in practice is shown in enforcing the Regulations in English Army Hospitals; but if, at present, equivocal women, as well as ascertained prostitutes, are not excluded (which very possibly they are) they should be. At the same time, a sentry may often be honestly puzzled as to equivocal or non-equivocal appearance, in these days of over-dressing. And some mistake, made by a stupid or brutal sentry, might lead to endangering the rule. This whole matter must be referred to men.12. Orderlies’ Attendance.12. With regard to the question of the “Regulation” number of Orderlies, viz., 1 to every 10 patients, it is to be observed,—(1.) 40-Bed Ward Minimum Size for Regulation Number of 1 Attendant to 10 Patients.(1.) A ward of 40 patients might be efficiently served (but it would be hard work) with1 Head Nurse—Female.3 Orderlies.With no number under 40 of patients to a ward, can the Regulation proportion of 1 attendant to 10 patients be adhered to.(2.) 20-Bed Ward requires 3½ Attendants.(2.) With a ward of 20 patients (cut, scheme, and arrange the hours and duties as you will), you cannot efficiently serve it with less than½ Head-Nurse—Female.3 Orderlies.And the other ward of this Head Nurse ought to be on the same floor.N. B.—The same number would quite as efficiently serve a ward of 25 or even 30 patients.(3.) 10-Bed Ward cannot be served by 1 Orderly + ⅕ Nurse.(3.) The Army system of 1 Orderly to 10 patients, with a number not exceeding 10 patients to a ward, is upset as immediately by one bad case among the 10, as by 9 to the 10.For, is the same Orderly to be on duty for the 24 hours?The difficulty is practically got over by the Army, with a permission that any “bad case” may select any one he likes of his comrades (out of the Depôt) to be “told off,” to attend upon him.This extraordinary regulation is equivalent to (and affords little other practical result, than) granting opportunity for any quantity of spirits, and illicit food, to be smuggled into Hospital, and it is clear that it would be totally inadmissible in a General Hospital, where the whole system of nursing would be under the most stringent discipline and supervision.(4.) Female Nurses not to be Substitutes for Orderlies.(4.) The introduction of Female Nurses into Military Hospitals is not intended to supply the place of Orderlies, but to perform a class of duties which never has been performed at all in the Army. Few other Hospital duties of those generally called such have been hitherto fulfilled, in Military Hospitals, exceptdiet-carrying,sweeping,and writing.(5.) Naval Hospitals Regulation Number of Attendants 1 to 7 Patients.(5.) In all Naval Hospitals, the Regulation number of attendants is 1 to every 7 patients, or 2 attendants for each ward containing more than 7 patients and up to 14. TheseAttendants or Nurses, in sailor’s language, have charge of the linen, bedding, and ward furniture, under the Ward Matron, and they are responsible for the proper care of the sick, and the due administration of the medicine, wine, and other medical comforts. They are on duty all day and watch at night in their turn, which is regulated by the Medical Officer in charge of the ward, in this or similar fashion:—a group of three contiguous wards is allotted during the night to two nurses, one begins her duty at 9 and ends at 1 o’clock, when she is relieved by another, who watches till 6. She patrols the three wards, resting in that one where there may be a case requiring more than ordinary attention. If there should be a case of fever, delirium, or other sharp seizure, extra Nurses, both men and women, are assigned to the charge of that special case, according to the urgency of its wants. The great majority of Naval patients are either convalescent, or suffering from trivial complaints, which do not impair their activity. They can therefore take care of themselves, and assist the Nurse during the day in cleaning the wards,&c.—and we know what good housemaids seamen make. The Nurses are paid one shilling a night for night watching. They have under the most severe circumstances two-and-a-half nights in bed for half a night out of bed.At Haslar Naval Hospital the system of Orderlies, as understood from the Principal Medical Officer, is as follows:—12 Orderlies are on a floor, to look after, say, 90 patients. These are divided for night duty into three divisions of 4 each; of these 4—2 are on from 9 to 2,A. M.2are on from2 to 8.The Head-Quarter room or ward is the one which has the most severe cases; this ward, then, the Watcher at night sits in, and makes the rounds of the others every now and then to see if anything is required. This system will of course be modified, according to the nature of the cases in Hospital. The other attendants do not sleep in the wards. The Nurses are male or female according to the discretion of the Principal Medical Officer.Civil Hospitals have even 9 Attendants to 44 Patients.In Civil Hospitals the number is as great of attendants to patients, and is mainly determined by the size of the ward:E.g., in one Hospital, where there are quadruple wards of 44 patients, 11 in each compartment, though the average number of patients is 48, the number of attendants is 7.In exceptional cases extra Night-Nurses, sometimes extra Day-Nurses serve particular patients. The labour, both of cleaning and of night-nursing, is much increased by the wards being four, separated by a large lobby.In another of the large London Hospitals, where there are to each ward,Patients.Attendants.2224⎫⎬⎭there are⎧⎨⎩1 Sister.2 Nurses.30there are⎧⎪⎨⎪⎩1 Sister.2 Nurses.1 Scrubber.34there are⎧⎨⎩1 Sister.3 Nurses.40there are⎧⎪⎨⎪⎩1 Sister.3 Nurses.1 Helper.In theLariboisièreHospital at Paris, where the wards hold 32 beds, 1 Sister, 1 Nurse, and 2 Orderlies on the Men’s side, 1 Sister, 2 Nurses, and 1 Orderly on the Female side, serve the ward efficiently.(6.) Same Number of Men will not do same amount of Work as an equal Number of Women would.(6.) One woman does the work of more than a man in a Hospital, speaking of the duties discharged by Under Nurses in Civil Hospitals; for men are not accustomed to these duties in England, as women are from their childhood.From this it is by no means to be inferred that women of the class of Under Nurses in Civil Hospitals should be employed in Military Hospitals, which unquestionably they should not. But it is to be inferred that the work will not be done efficiently, with a smaller number of men than would be employed of women.(7.) Hospital Attendance an entirely new subject in the Army.(7.) The question of attendance has scarcely been intelligently considered in the Army at all. And hardly any practical answer has yet been given to such questions as the above.I conceive it to be practically impossible to serve 4 wards, as proposed at Netley, viz., of 9 beds each, with1 Head Nurse,4 Orderlies.For, as has been said, one bad case in each ward, makes this economy as unmanageable as nine.(8.) Hospital Wards in the Army little else than Barrack-Rooms at present.(8.) A ward in a Military Hospital now may often be little else than a barrack-room, with an Inspection by a Medical Officer twice a day. It is designed to make it by the new Regulations into a place where the sick must be and always will be suitably attended. But this cannot be done by such a scheme as—1 Female Head Nurse⎫⎬⎭to⎧⎨⎩50 Patients, in (say)6 Orderlies6 Netley Wards;though this attendance would be more than sufficient for 50 cases in one ward; but such a ward is considered in a sanitary sense too large. Two wards of 30 beds each on the same floor would be efficiently served by such a Staff, however; and there would be no sanitary objection.
5. Washing, how to be done? Rule to compel the Nurses toput it out.
5.Washing.—Except in war-emergencies, this must not be suffered to be done by the Nurses, they must be compelled to put it out. I would not trouble the Authorities about this; the Nurses can afford it, and the more things are simplified the better. In out-of-the-way districts, the Matron might arrange with a laundress, the Nurses making a fair payment. In war-emergencies, if possible, provide a strong washerwoman, but this would have to be settled each case on its merits. Except in emergencies they must not wash; it takes up far too much time; it takes up strength which is wanted for other things; and washing and drying either in wards or nurses’ rooms is unhealthy and objectionable. There must be a ruleas to this: some worthy souls would scrub at every rag, rather than pay a few pence weekly. The Nurse ought, however, to be compelled to have certain changes of linen weekly, which some will not, if they pay for it themselves.
6. Cleaning their own Rooms. No Orderly, on any pretence, must enter a Nurse’s Room. Scrubbing the only thing the Matron may arrange for a Soldier’s Wife to do. Nurse must do nothing of her own in Ward, or Ward-kitchen, or Orderlies’ Kitchen.
6.Cleaning their own rooms.—I well foresee sundry difficulties in the little rooms at the entrance of their wards, where I hope it will be managed to quarter the Nurses. But there is no other way of fairly and really working a ward; and I trust this plan will receive a fair trial. For efficiency, also for comfort, it is most objectionable to make the Nurse sleep at a distance from the patients. This is one of the points on which theories, and the practical working of things, are very divergent. It is an excellent thing when the Head-Nurse’s room opens into the ward and when part of the upper part is of glass, with a thick curtain, so that she can see into the ward, without being seen. Let each Head-Nurse have a small room, with a window opening into external air, with a curtain making an alcove, behind which there should be a small iron bedstead, with good bedding, and a washing table; and in the foreground a table, a small one for meals, a chest of drawers, and a comfortable arm-chair, two chairs, and I should add a sofa. Each room should have a few shelves on the wall, and a large cupboard or small closet with broad shelves, and space at the bottom to stow away the Nurse’s box. Simplification and avoiding all trouble which can be spared to the Departments are very important. I would not therefore insist upon a little kitchen for the Nurses, nor upon a very capital arrangement in some of the Sisters’ rooms in Guy’s Hospital, where, behind a decent little doorinthe sitting-room, there is a sink, with water laid on, a little safe for meat,&c., at top, and a complete little apparatus of the very few utensils required for cooking one woman’s meals; so that a Nurse can cook and wash-up, in her own room, without carrying things out of it. This is much better than a kitchen, if the Nurse is to cook her own meals; but, as above stated, I would rather she did not. One room, with a curtain making an alcove, is much better than two. The Queen is saved fuel; the Nurse is saved cleaning two rooms; and if fuel is only issued for one, she sleeps in a warm room, instead of one where there never is a fire, and where her things get damp and spoiled. Often, where Head-nurses have two rooms, one is built without a fire-place. Condenseand simplify all things—one great object is to form a body of useful hard-working women, of simple self-helping habits. Two Nurses’ rooms should be together, but separate. Sudden illness might occur, and the two women should be at each other’s summons. The Quartermaster-Generalmustgrant acabinetbetween the two: this ismust, notmay. The Superintendent-General must see to this herself, at first at all events: thereisa singular obtuseness in the small officials, by whom these things are managed: if not overlooked, they will be sure to put the construction in a particularly awkward, exposed place. These things do enter into an Englishwoman’s daily comfort or misery—it is worth arranging them decently in the first instance.
Now as to the cleaning of these rooms. Head Nurses generally are far too much disposed to make servants of their nurses; put orderlies for nurses, and this objectionable tendency would be a hundred-fold more objectionable. The Matron must make it an absolute rule, that the only thing an orderly does for a nurse is to carry her box in and out on the two grand occasions of her entering and leaving the Hospital. The one thing which in a Civil Hospital, an Assistant Nurse should be allowed to do for the Head Nurse, is the cleaning her fire-place, a thing done in a few minutes, and with satisfaction, by women who have done it all their lives; but a dirty tedious messing business to those who have not. But never mind: the orderly must never enter the Nurse’s room: she must do it, and learn to do it. The prosaic little business of black-lead, ashes, and mess lying on the threshold of the work will do good rather than harm. And even black-lead is unnecessary, as a varnish now obtainable looks better. The orderly must never enter the Nurse’s room—asine quâ non. The Nurses should have, at their choice, a carpet, not nailed down, or none. In either case the room will require scrubbing, once a week if no carpet, (which is best and cleanest in Hospital life), seldomer, if carpet. Now the Nurses should not be required to scrub their own rooms—it is useless waste of strength—it makes their hands coarse and hard, and less able to attend to the delicate manipulation which they may be called upon to execute—and with all thenursing properwhich ought to fall upon them, and not upon the orderlies, their time can be better occupied than in cleaningtheir own rooms. Also, while trying to keep clear, on the one hand, of the tribe of “fine ladies,” it will be possible, on the other, if such menial offices are to be performed, to fall into the opposite mistake and to fail in obtaining the class of women desirable to fill such important trusts. Let the Matron consent to a charwoman, soldier’s wife, or some one person named and defined, and found, to be paid by the Head Nurse, to come for the two hours, which, at furthest, this business will take. It would be well worth while for the Matron to look out and provide two or three strong women to do this, by fixed rotation—each Nurse making a fair payment—and to ascertain that they are in and out of the Hospital by a particular hour, so as to prevent these external persons doing other things than scrubbing. But do not trouble the Departments as to this—the more things are simplified, and the fewer expenses are in connection with the Nurses, by far the better.
Take the trouble to see that a tidy useful fire-place is in each Nurse’s one room. Some fire-places will consume thrice the fuel of one which can do ten times more work. A compact useful little fire-place, to burn as little fuel, and do as much business (in a very small way) as possible, is a thing of daily use, economy, and comfort.
The nurse should not do anything of her own in the ward, or the ward or orderlies’ scullery, if there is such a place. This is a matter requiring some decision.
7. In each Ward to be Closet, with Shelves, Table with Drawers, Nurse with Keys. Nothing to be kept in Nurse’s Room. Linen, Dressings, Stimulants to be kept in Ward Closets.
7. Let there be in each ward a closet, or, better still, a dresser,[8]with broad shelves, and a large table with large drawers, of which closet or dresser, and drawers, the nurse has the sole keys. Let the articles of linen which are kept in the ward be there; also the bandages, lint, old linen, oilsilk, ointments,&c.,&c., which should always be, some at hand, some in reserve; also the wine and brandy ordered for the men. Let the nurse never be allowed to deposit Hospital property in her room, which, if there is no place for it, shemustdo, and it is much better she should not.
8. Matrons 200l.per annum, Quarters, and a Maid. A woman for the Linen, ranking and paid as a Nurse, but never entering the wards.
8. With regard to the Matrons, though as Locke says of tutors, there are all kinds of persons to be found, it is certain the right persons are not always found; and these officers will take time to find, at the outset especially. Let them be (if it be possible) of the middle class; if it be possible, middle aged, active women, widows of officers or army surgeons. A vast deal of struggle is ever going on in professional life; a vast deal of silent, decorous misery ever follows on the premature deaths, the compelled early retirements, the sundry chances and changes which ever abound in the army of England. So far as it goes, andcæteris paribus, it would be right, just, and expedient to give a preference for these matronships to widows of officers and army surgeons. Try to secure thorough principle, sense, activity, and steady discreet ways; never mind a little vulgarity of manner; that the different orders should have their indefinable perpetual distinctions of manner as of other things, is perhaps for a long time to come in the essence of things. Two or three women of the stamp of the Matrons of a few of our Civil Hospitals would be very valuable. If the Matron do not get tired of what, unless one keeps one’s secret thoughts fixed on the meaning and the end of all things, is coarse, thankless, up-hill work enough—she will in the course of years accomplish great good. But she must have principle, sense, heart, and a firm cheerful mind. She must be not under thirty and, if possible, not over forty, on appointment. Should her being without children be made asine quâ non? Children—poor little things—are wanted nowhere in the way of business, but do not be too strict about this: they are sometimes pledges to other things than fortune—thoughts, anxieties, and labours for them, concentrate and steady a mother’s heart—there will be fewer adventurers. Maternalnursesmust upon the whole be discouraged, because upon the whole the disadvantages seem to overweigh the advantages.[9]But the Matron’s office and duties are different; she is not fixed to a great ward of patients; and her having children should not be a bar, especially if theydid not live with her. Young and grown-up daughters are much in a Matron’s way; sons matter much less.
The greatest Civil Hospital gives its Matron 200l.and ahouse, the other great Hospitals, 150l., and ahouse. The London Hospital gives 150l., and a couple of good well-furnished rooms, and a servant. Ahouseis an impediment to a Matron’s duty. She is seen arriving in the wards, and she is more or less hindered in entering them. From her rooms she issues and re-issues, unexpectedly, and much more efficiently. 200l.and quarters is not at all too much.
The Matron must be responsible for the storing, mending, and distribution of the linen, and for returning to the laundry any linen not properly washed or dried. Linen ought never to be dried in the wards, a process both inconvenient and unwholesome. The Matron ought to have a steady, respectable woman, certainly not below the rank and pay of a nurse, to be responsible to, and under her, for the linen, otherwise the proper care of the linen will take up far too much of her time. This is important. If, however, a Nurse should be thus set aside for the Laundry, she must not be allowed to enter the wards; otherwise she will unconsciously become a gossip and mischief-maker. I would term her “Linen Nurse,” not Assistant. The Matron should also have a steady, properly paid servant. A Matron of the proper sort has quite other things to do at a leisure moment, than to keep her wardrobe in order. She must have a servant; but it seems to be advisable to simplify things, and condense payments as much as possible; and I would rather consider this in the salary, and let the Matron find and pay her own servant. Try to have the servant’s room near the Matron’s. These minutiæ, once provided for, enter much into the daily working and comfort of things.
The dress of the Matrons is a difficult thing to settle. Sometimes a Matron is afflicted with a taste for either gorgeous or elegant apparel, which the Nurses are invariably proud of, admire and humbly emulate. This sort of thing would be really out ofplace in a Military Hospital, and would moreover sadly discompose the Nurses with their plain caps and gowns. How would it be to allow the Matrons the choice between a Regulation dress and a plain black or brown silk gown?
It will take much thought to decide whether the Matrons should all be paid alike, or whether climate and size of Hospital enter into this. On the one hand they undertake a service, of which almost the first regulation very properly is, that they undertake to go to all parts of the world as soon as sent; on the other hand, certainly some climates wear health and life much quicker than at home.
The Matrons out of the three kingdoms have increased responsibility, and can do more mischief, if incompetent or untrustworthy.
If the Matron has increased pay abroad, it would not do not to augment that of the Nurses. This is an important matter; and as it is on all accounts necessary that Matrons and Nurses should on their engagement thoroughly understand the nature of the service they undertake and, of course, a serious part of the service is that it involves sudden and long removals, it would be necessary to define upon what terms they go abroad. Yet it never would do, for reasons which will readily be perceived, to make the foreign stations objects of desire to Matrons and Nurses. These stations will always be so far the most anxious, that they will always be the most removed from the Superintendent-General’s inspection and immediate rectification of anything that goes wrong. They will also be, in various ways, the most trying to Nurses. The rules once settled, every Matron and Nurse refusing to go abroad when ordered, ought at once to be discharged, and to forfeit all re-admittance into the service and all pensions. On the whole, I think the Matrons should all be paid alike. But inasmuch as foreign service necessitates more wear and tear to the constitution, one year should count as equal to two years of service for pension, in case of disability. The same should be made applicable to the Nurses. As the advantage is distant, it would, in a great measure, do away with any desire for foreign service.
Volunteering for foreign or war-service must be the exception—careful selection the rule. The “adventurers” will be generally ready to volunteer, and it would be too much to hope that we shall always, perhaps ever, be entirely free from that tribe; the most we can hope is soon to discover and get rid of them. Foreign stations will never do for an untried Matron or Nurse. At the same time it is most desirable not to change the Executive officers of any Hospital more than can be avoided.
But let there not be too many rules at first; see how things work, and take one step at a time.
The selection of exclusively middle-class Matrons seems to be important.[10]Their order will disarm one source of opposition and jealousy; plenty more will remain, inseparable from the work; but it is good to get this out of the way.
The name of Matron is the same as in Civil Hospitals. In many respects the office and duties are different:e. g., the Matron in Military Hospitals must exercise a far more constant supervision in the wards. But this will require great discretion on her part. It is the practice of most Civil Hospitals for the Matron never to enter the wards till the Nurse’s dressings are over. It would be advantageous to modify this. But, at the same time, the Matron must understand Hospital Nursing, or she may make very serious mistakes in either reprimanding or directing the Nurse as to technical matters. She must be a person who knows herself what she has to see that others know; or she will get herself, with or without the Nurse, into very injurious errors. There is much in a name; and, in some respects, that of Superintendent would better denote her office, as regards the Nurses, would add to her authority, which is desirable, and would point her out as acting under the Superintendent-General.
Incorporate among the Nurses whatever women of the higher orders may be admitted into the Service at first. If inefficient and unfit they are far better altogether eliminated. If thoroughly efficient as Ward Nurses, if thoroughly obedient and respectful to the Matron, if they have sense and heart to gradually leaven, not coldly withdraw from occasional companionship with the other Nurses, they will, in the course oftime, effect quietly a great deal of good.
There should be some Rule of this kind—
Any Matron or Nurse who may receive permission to serve Her Majesty without pay shall be, in all respects, bound by and amenable to the Regulations on pain of dismissal from the service, without permission of re-entering it.
If this cannot be done, money can easily be returned in one shape or other; but it would have a good moral effect on the Nurses to allow of the admixture of unpaid Nurses, provided they are strictly bound by the same Regulations, and distinguished by no sort of peculiar designation.
The Surgeons will dislike these unpaid Nurses; but, in the long run a firm, discreet woman,who is an efficient Nurse, can get on with any Surgeonwho has his sick at heart. The Matron also will not at all like them, at first, but will find that she can rely upon them and that they quietly and effectually help her with the other Nurses: and, if she has her heart in her work, she will end by being just, though, perhaps, always a little extra strict with and jealous of them. The other Nurses will have, at the first, a strong little touch of republicanism towards them, which will gradually wear off, and, with God’s help, a higher and truer moral tone, and a simpler and more useful kind of habits among them will prevail, than would otherwise be the case. As for the patients, with all their faults, trust them—trust the English soldier, and the peasantry from which he springs. What these poor fellows are we know, and need not discuss. They are worth suffering a good deal for; please God in the long run good will be done. If only we can keep clear of the false, pernicious, and derogatory system of puffery and fuss which others, for their own purposes, and from vague, silly good-feeling have wound around this work—a work essentially unpopular the moment we come to details! We have learnt what reality is and what its presence or absence in this business imports. As for the many and great other difficulties of the work, they must be appreciated, they need not be dreaded. The purpose is a good and noble one, and God grant it success! All we have to do is, to do our utmost, and leave the event to Him.
9. Nurses—begin with few at first.
9. As for the Nurses the material must be formed. If a few respectable soldiers’ widows, including, and all the better, non-commissioned officers’ widows, could be found,cæteris paribus, a preference should be given to widows of the Service.
Except in emergencies Nurses should not be taken under thirty, or above forty[11]years of age. These women are Head Nurses. Most of the Civil Hospitals take no Head Nurse after forty.
One caution in engaging Nurses is perhaps not sufficiently attended to. Certificates, without personal inquiry and answers to distinct questions, are not worth the paper on which they are written.
As to engaging any Nurses out of the great Hospitals, for sundry reasons, this should be done as little as may be.
Let us begin, for the sake of God and this His work, with few women. Extension is easy—to occupy too much ground at first would be, I do in my conscience believe, an irretrievable mistake.
No unnecessary Nurses should be suffered in Hospital; and no Nurse in charge of wards should be required to do needlework for the Hospital. There should be no superfluous hands; and the less a Nurse enters another’s ward the better.
In case of suspension of a Nurse for misconduct, temporary assistance must, however, be obtained; and this might be either appointing another Nurse, to do, for the time, such duty in the suspended ward as she could do in addition to her own, or putting in a temporary substitute.
All such dislocation of the Service, necessary and useful for emergencies and holidays, should, nevertheless, be made to take place as seldom as may be.
No Nurse, during her suspension, should be allowed to enter any ward of the hospital.
Any Nurse asking or accepting a present, whether in money or in kind, from any patient, or friend of any patient, whether during his illness or after his death, recovery, or departure, must be at once suspended from duty, her pay immediately cease, and the Superintendent-General be apprised of it, who, if satisfied of the truth of the charge, should immediately dismiss her.
Two hours daily for exercise or recreation should be allotted to the Nurses, during which two hours they are to be considered relieved of the responsibility of their wards. But I would not be too absolute in requiring them to go out: sometimes to lie down or sit still for an hour or two will do more good than a walk. Give them two hours for optional exercise. Head-Nurses cannot have more of fixed leisure. They must get time for private occupation as they can: very often not at all; and no Nurse fit for her place will, of course, in emergent states of her ward, leave it. Also the Matron must not worry herself or them, if an anxious Nurse sits up part of a night or a whole night with bad cases.
To a certain degree the Matron will find it better to allow a little liberty and choice, in the matter of times and hours, (always excepting after proper hours,i. e., after dark) to the Nurses, who are Head-Nurses, than to attempt making them mere machines. An uniform system, as far as possible, and a little range to each, will answer best. But do not hurry the uniform system too much; take time: this is very important.
The Nurse should, every morning, at an hour to be fixed by the Chaplain or Matron, read aloud in the ward, the Confession, the Lord’s Prayer, the Collect for the Week, the Collect for Grace, and the Benediction; and every evening, at an hour to be fixed by the Chaplain or Matron, she should read aloud in the ward the Confession, the Lord’s Prayer, the Thanksgiving, the Collect for Aid, and the Benediction.[12]This would Christianize things, instead of heathenizing them; and I believe not a soldier would dream that his conscience was injured by it. The Roman Catholics and Presbyterians might be allowed quite to refrain, if they chose, which they would not. It would be necessary for the Chaplain-General to approve of and direct in this, and best to wait a year or two before beginning it.
The prayers should be very short, the whole not more than five or six minutes each time, and the Nurse should read them, the men joining at the proper times.
In some Civil Hospitals the prayers are far too long and are gabbled over by some patient, perhaps the worst character and the best scholar in the ward, or are stumbled through by some little boy, upon whom the others cast the distasteful office, with circumstances of irreverence, partly unintentional and partly shocking. AtSt.Bartholomew’s Hospital the very short morning and the very short evening prayers are printed clearly on each side of a card, which is affixed to each bed; and each morning and evening the Head-Nurse reads them aloud: the difference is very great.
10. Have the Diets sent hot and ready-divided from the Kitchen.
10. The Colney-Hatch Lunatic Asylum has a diet system worth inquiring into; nothing is fetched by the Nurse, the Medical Officer writes the diets on a large slate which is ready for him outside the ward.
The great advantage of this seems to be, that the Nurse’s time is set free from a good deal of arithmetic and some writing; also that each man’s portion is served himhotfrom the kitchen, not cut up laboriously by the Nurse. In most Hospitals the Nurse cuts and divides the diets; in the London Hospital she moreover weighs them. All this takes a great deal of time. If the patients can get the divided portionshotfrom the kitchen, it is far preferable.
AtSt.George’s Hospital the portions are sent hot and divided from the kitchen.
11. The less any Patient is made into an Orderly by the Surgeon the better. The Nurse should have Regulations to invoke to allow her to do her duty.
11. It should be distinctly settled by whom poulticing, fomenting, and all minor dressings, applying leeches and blisters, and giving enemas,[13]are to be done.
It would be advisable to consider whether the Nurse ought not to instruct the Orderlies in some things. This, if it did not clash with Orderlies’ Rules, would make these men, especially those ordered for foreign service, much more useful than they are now, without such teaching.
It will, however, be essential that there should be no clashing between the Nurses’ Regulations and those already or to be issued to the Orderlies. And for this, among other reasons, it is essential to establish a direct channel of communication between the Director-General and Superintendent-General of Nurses.
Ward Medical Officer to give Directions to Nurse.
I think, upon the whole and with reference to preventing, as far as rules can do it, the obstruction of the Nurse’s duty, by adverse or inexperienced Medical Officers giving orders to Ward or Assistant Ward-Master, Orderlies, or patients, instead of to her, that it is better to charge him to give the Nurse his orders as to the sick.
All the above-mentioned things should be done by the Nurse,i. e., by her habitually and as a rule; occasionally letting an orderly do them, under her own eye, in order that he may learn, as well by doing them sometimes himself as by often seeing her.
The reasons why all these things must be clearly settled beforehand are these:—
I. Adverse Medical Officers will make all use of counter-regulations.
II. Medical Officers who give fair play will find it impossible to settle the matter, if, on ordering,e. g., leeches, the Orderly shows Rule so and so by which he does it, and the Nurse Rule so and so by which she does it. The existence of the old regulations and the arrival of the new ones, about the Medical Staff Orderlies, were made great use of against our work, by some of the Medical Officers, after the heavy pressure of the war was over. So, at Scutari, a Principal Medical Officer took away and would not restore the practice of the nurses giving medicines, in which he was borne out by an existing rule. Contradictory rules are miserable things.
Unless the Matron’s authority is supported by the PrincipalMedical Officer the Patients always suffer. The Nurse is the only proper person to be responsible for the directions of the Medical Officers being carried out in a General Hospital.
III. It will enable the Matron to stop all nonsensical prudery, on the part of the nurses, and to require that they should do what they undertake to do, and not pass off to an Orderly, still less to a patient, the duties they should discharge themselves.
As a general rule there is a good deal of this false modesty on the part of Nurses, especially of Head Nurses. In individual cases it is a serious thing to shake even false ideas of decorum: in laying down general Rules it is the more important to lay down as duties what are such. Suppose an application of what the French call “la petite chirurgie” ordered. The Head Nurse “never dreams of doing such things.” The Nurse, following her superior’s false shame of duty, transfers the business to an ignorant patient. In some cases great harm has arisen thereby to the Patient. In other cases, but not the majority, after such an order given, the Head Nurse goes quietly to the bed, draws the curtain round it, and makes the application herself—saying “she always did that herself, as it was a business requiring care, as the patient was often disposed to resist, and as she was thus certain that it was properly and effectively done.” I have always admired and respected such women; but they are not the majority. Very often patients are allowed or left to do things for themselves, which they cannot do properly, or when they ought not to be trusted to inflict the pain on themselves which doing things properly often causes.
The practice of allowing some particular patient to become a sort of half orderly in the ward, letting him always attend some particular case, or give general help in severe cases, is most reprehensible. It is never allowed, whether in Civil or in Military Hospitals, without very bad consequences to the discipline of the ward. Where extra help, in lifting,&c., is required, let the Nurse require the most convalescent of the patients to help, but let her carefully refrain from selecting any patient or allowing any patient to put himself forward, as a regular help or quasi-Orderly. As an almost invariable rule it will be found that the less patients do for each other the better for themselves, and for the discipline and the good feeling ofthe ward. Let them be made useful in the wards, as far as possible, in such lighter cleaning,&c., as a patient can properly do (here, again, discretion is required, or a lazy Orderly will lay undue burdens on a willing patient); but the less they do for each other undoubtedly the better for all parties. I would not, however, expressly exempt the patients from being made useful in nursing the sick. A lazy or ill-conditioned patient might make it a handle to refuse to do or grumble at doing things which he ought to do, such as (a thing frequently required) giving and emptying a bed-pan to an ordinary patient who cannot leave his bed, while the Nurse and Orderlies are doing other things in the ward; assisting to move a helpless patient, if all the Orderlies are not at hand; sometimes watching or attending for an hour or so a critical case,&c.,&c.,&c.What the Superintendent-General and all Superintendents must be especially vigilant against is selecting any particular patient or allowing a willing patient constantly or often to do these things, and to become a quasi-Orderly to the ward or to any patient in it.
Assistant-Surgeons, partly from inexperience and partly from spite, sometimes make this sort of quasi-Orderly of a patient. The Nurse should have the power of respectfully saying, in such a case, “The Regulations order me to do so and so, sir: I beg you to let me do my duty.”
It is an important and should be, if possible, an invariable rule that no discharged patient is ever to enter any ward. Soldiers are, in many respects, on a different footing, as to each other, from Civil patients. The above provision is perhaps rendered thereby (not the less, but) the more important for the good order of the ward. Still this, desirable in (and the rule in several) Civil Hospitals, might be considered by Military as well as Medical Officers to interfere too much with the feeling of comradeship which, in its measure, is so essential a part of the soldier’s very peculiar condition. The following rules however might, at all events, be carried out. Some of them are actually in the “Hospital Regulations.”
As quietness is indispensable in Hospitals, every duty should be performed with the least possible noise, more especially at night. Every patient must be in bed by 8 o’clock in winter, and 9 in summer; and no conversation must be permitted afterthat time. Patients should be made useful in the wards, as far as possible; but should fetch nothing into them. And no discharged patient should be permitted to enter any ward, except in the fixed visiting hours. The Governor, where there is a Governor, or the Principal Medical Officer, will fix the visiting hours; which shall not be more than two hours during each of three days of the week. [Take proper advice as to whether this maximum is too short. It is fully enough for Civil Hospitals, but Military Hospitals are in sundry respects essentially different.]
In the discipline of all Military Hospitals, besides the prohibition of all swearing and foul language included in the Articles of War, is included the non-admission, or if by oversight admitted among visitors, the immediate expulsion of all disorderly persons. (Query—whether not to specify prostitutes.)
I very much wish that Hospital Sentries in General Hospitals might keep out all visitors, except in the fixed visiting hours. And I very much wish that a stringent rule were made as to female visitors, both in Regimental and in General Hospitals. Proper Military as well as Medical advice should be taken on this point. It might not do to exclude them altogether; and, if soldiers’ wives come, it might be better to admit also all respectable-looking women, for it would be useless attempting defining as to sisters, aunts, friends,&c.,&c.; though, except in the case of dying patients, all women, except their wives and mothers, are better away. I do not know what amount of strictness in practice is shown in enforcing the Regulations in English Army Hospitals; but if, at present, equivocal women, as well as ascertained prostitutes, are not excluded (which very possibly they are) they should be. At the same time, a sentry may often be honestly puzzled as to equivocal or non-equivocal appearance, in these days of over-dressing. And some mistake, made by a stupid or brutal sentry, might lead to endangering the rule. This whole matter must be referred to men.
12. Orderlies’ Attendance.
12. With regard to the question of the “Regulation” number of Orderlies, viz., 1 to every 10 patients, it is to be observed,—
(1.) 40-Bed Ward Minimum Size for Regulation Number of 1 Attendant to 10 Patients.
(1.) A ward of 40 patients might be efficiently served (but it would be hard work) with
With no number under 40 of patients to a ward, can the Regulation proportion of 1 attendant to 10 patients be adhered to.
(2.) 20-Bed Ward requires 3½ Attendants.
(2.) With a ward of 20 patients (cut, scheme, and arrange the hours and duties as you will), you cannot efficiently serve it with less than
And the other ward of this Head Nurse ought to be on the same floor.
N. B.—The same number would quite as efficiently serve a ward of 25 or even 30 patients.
(3.) 10-Bed Ward cannot be served by 1 Orderly + ⅕ Nurse.
(3.) The Army system of 1 Orderly to 10 patients, with a number not exceeding 10 patients to a ward, is upset as immediately by one bad case among the 10, as by 9 to the 10.
For, is the same Orderly to be on duty for the 24 hours?
The difficulty is practically got over by the Army, with a permission that any “bad case” may select any one he likes of his comrades (out of the Depôt) to be “told off,” to attend upon him.
This extraordinary regulation is equivalent to (and affords little other practical result, than) granting opportunity for any quantity of spirits, and illicit food, to be smuggled into Hospital, and it is clear that it would be totally inadmissible in a General Hospital, where the whole system of nursing would be under the most stringent discipline and supervision.
(4.) Female Nurses not to be Substitutes for Orderlies.
(4.) The introduction of Female Nurses into Military Hospitals is not intended to supply the place of Orderlies, but to perform a class of duties which never has been performed at all in the Army. Few other Hospital duties of those generally called such have been hitherto fulfilled, in Military Hospitals, except
(5.) Naval Hospitals Regulation Number of Attendants 1 to 7 Patients.
(5.) In all Naval Hospitals, the Regulation number of attendants is 1 to every 7 patients, or 2 attendants for each ward containing more than 7 patients and up to 14. TheseAttendants or Nurses, in sailor’s language, have charge of the linen, bedding, and ward furniture, under the Ward Matron, and they are responsible for the proper care of the sick, and the due administration of the medicine, wine, and other medical comforts. They are on duty all day and watch at night in their turn, which is regulated by the Medical Officer in charge of the ward, in this or similar fashion:—a group of three contiguous wards is allotted during the night to two nurses, one begins her duty at 9 and ends at 1 o’clock, when she is relieved by another, who watches till 6. She patrols the three wards, resting in that one where there may be a case requiring more than ordinary attention. If there should be a case of fever, delirium, or other sharp seizure, extra Nurses, both men and women, are assigned to the charge of that special case, according to the urgency of its wants. The great majority of Naval patients are either convalescent, or suffering from trivial complaints, which do not impair their activity. They can therefore take care of themselves, and assist the Nurse during the day in cleaning the wards,&c.—and we know what good housemaids seamen make. The Nurses are paid one shilling a night for night watching. They have under the most severe circumstances two-and-a-half nights in bed for half a night out of bed.
At Haslar Naval Hospital the system of Orderlies, as understood from the Principal Medical Officer, is as follows:—12 Orderlies are on a floor, to look after, say, 90 patients. These are divided for night duty into three divisions of 4 each; of these 4—
The Head-Quarter room or ward is the one which has the most severe cases; this ward, then, the Watcher at night sits in, and makes the rounds of the others every now and then to see if anything is required. This system will of course be modified, according to the nature of the cases in Hospital. The other attendants do not sleep in the wards. The Nurses are male or female according to the discretion of the Principal Medical Officer.
Civil Hospitals have even 9 Attendants to 44 Patients.
In Civil Hospitals the number is as great of attendants to patients, and is mainly determined by the size of the ward:
E.g., in one Hospital, where there are quadruple wards of 44 patients, 11 in each compartment, though the average number of patients is 48, the number of attendants is 7.
In exceptional cases extra Night-Nurses, sometimes extra Day-Nurses serve particular patients. The labour, both of cleaning and of night-nursing, is much increased by the wards being four, separated by a large lobby.
In another of the large London Hospitals, where there are to each ward,
In theLariboisièreHospital at Paris, where the wards hold 32 beds, 1 Sister, 1 Nurse, and 2 Orderlies on the Men’s side, 1 Sister, 2 Nurses, and 1 Orderly on the Female side, serve the ward efficiently.
(6.) Same Number of Men will not do same amount of Work as an equal Number of Women would.
(6.) One woman does the work of more than a man in a Hospital, speaking of the duties discharged by Under Nurses in Civil Hospitals; for men are not accustomed to these duties in England, as women are from their childhood.
From this it is by no means to be inferred that women of the class of Under Nurses in Civil Hospitals should be employed in Military Hospitals, which unquestionably they should not. But it is to be inferred that the work will not be done efficiently, with a smaller number of men than would be employed of women.
(7.) Hospital Attendance an entirely new subject in the Army.
(7.) The question of attendance has scarcely been intelligently considered in the Army at all. And hardly any practical answer has yet been given to such questions as the above.
I conceive it to be practically impossible to serve 4 wards, as proposed at Netley, viz., of 9 beds each, with
For, as has been said, one bad case in each ward, makes this economy as unmanageable as nine.
(8.) Hospital Wards in the Army little else than Barrack-Rooms at present.
(8.) A ward in a Military Hospital now may often be little else than a barrack-room, with an Inspection by a Medical Officer twice a day. It is designed to make it by the new Regulations into a place where the sick must be and always will be suitably attended. But this cannot be done by such a scheme as—
though this attendance would be more than sufficient for 50 cases in one ward; but such a ward is considered in a sanitary sense too large. Two wards of 30 beds each on the same floor would be efficiently served by such a Staff, however; and there would be no sanitary objection.