Part 15

It is essential for the woman who intends to succeed in this profession to have excellent physical and mental health, though great muscular strength is not necessary. During student life and in practice, every care should be taken of the general health--exercise in the open air being especially necessary, though this should not be too energetic in character. It is a well-known fact that male dentists doing careful and conscientious work, cannot, as a rule, stand the strain for many hours daily after they have reached middle age, and the intending student should consider this point.

The prolonged hours of standing in a cramped position, the confined space, the exactitude required for minute and painful operations, are some of the causes of this overstrain. Great self-control and will power must be exercised as the patients, especially children, are frequently nervous, and confidence must be imparted to them if the work is to be well done.

The British Dental Association and the Odontological Society are both open to women, and male practitioners have always displayed the utmost courtesy though some prejudice must be expected. The general public apparently welcome the advent of women dentists as the few qualified women in London and the Provinces have excellent practices. It is curious, however, to note that few Englishwomen have taken up the profession, there being about twelve practising in the United Kingdom, though in Germany, Russia, and the United States there are great numbers of women practitioners.

With regard to restrictions from which women at present suffer, one dental hospital only is open to women in London, and, until recently, no posts could be obtained. But as more women qualify, these disadvantages will probably be removed. It is also extremely difficult to obtain mechanical work in private work-rooms. Women should bear in mind that they require exactly the same facilities for study as men, and try to get admittance to all hospitals and posts on an equal basis--_i.e._, the salary should be equal for equal work, and a smaller fee should not be accepted.

In deciding whether a practice should be started in London or a provincial town, the question of capital must be carefully considered, as it is improbable that the expenses will be met during the first year of practice. The upkeep necessarily varies with the locality chosen, and a minimum capital of £150 is desirable.

Pioneer women must be prepared to do their work conscientiously, and to the utmost of their ability, and they must always remember that their work will be very severely criticised.

This necessitates frequent inspection of both the clothing and persons of the children. Certain cases which are found to need attention are also visited in their homes. The school nurse is so much alone in her work that she requires to be very experienced and her powers of observation to be highly trained in order to enable her to detect signs of ill-health in its early stages. Firmness and kindness are constantly required in dealing with parents, and tact and consideration in her dealings with all with whom her work brings her in contact.

In the London area the salary begins at £80 rising by £2, 10s. yearly to £85, and then by £5 yearly to £105. Uniform and travelling expenses, within the county, are provided. The nurse is required to contribute to the superannuation fund from which she can ultimately draw a pension if she remains all her working life in the service of the Council.

The hours of work are from 9 A.M. to 4.30 P.M. five days weekly, and from 9 to 12.30 on Saturdays. Clerical work must be done out of school hours. Holidays are arranged during the school holidays.

There are 128 nurses working under one Superintendent, two Assistant-Superintendents, and four Divisional Assistant-Superintendents.

_B_. There are 42 nurses attached to schools for the physically defective whose special duties are concerned with the care of the crippled and delicate children who attend these schools. Certain special precautions against injury and strain are necessary for these children, and the nurse receives instructions concerning these from the visiting doctor. The salary is the same as that mentioned above, and the nurses get the school holidays. At open-air schools the nurse's work is somewhat similar to that in the schools for the physically defective.

_C_. There are 8 nurses now working under the Infant Life Protection Act.

All women who undertake the care of an infant for payment have to be registered. Of such children, a large proportion is illegitimate. It is the duty of the nurses to visit every such case. Each nurse has an area allotted to her; the work is arduous and responsible as the visitor has full powers under an Act of Parliament summarily to remove the child if the conditions required by the Act are not complied with. The nurse who undertakes this work should have been trained in maternity work (and if possible have been examined by the Central Midwives' Board). She should also have her certificate from the Sanitary Institute as she is expected to report on the sanitation of the premises as well as on the condition of the child. There is a considerable amount of clerical work in connection with these posts.

The salary of these nurses is good, compared with the usual salaries for nurses--£120 to £150, with a further rise to £200 after ten years of service.

The superannuation fund, which is compulsory for all permanent officers, yields a provision of not less than one-third of the average rate of pay in a case of complete breakdown in health after ten or more years in the service of the council. The retiring age, apart from breakdown, is sixty-five years.

The conditions of work in the Provinces are much the same in general outline as those described above, which prevail in London, except that in the country the nurse often undertakes in addition the work done in London by Care Committees and Attendance Officers. This, although it increases her work also increases its variety.

VIII

NURSING IN HOSPITALS FOR THE INSANE

Mental nursing as a profession for educated women has much to recommend it. It is of absorbing interest to those of a sympathetic nature and of a scientific turn of mind, and it develops all the finer qualities, self-control, patience, tact, and common-sense. It gives scope for originality and accomplishments of every kind. The work itself is difficult, and is the one of all the many branches of nursing which demands the closest personal devotion and service, great as is the necessity for these in all forms of a nurse's work.

Mental nurses are employed in (1) county asylums, (2) mental hospitals, (3) private work.

(1) _County Asylums_--These may take from 1,000 to 2,000 patients each. They are usually situated in the country with healthy surroundings and large grounds, and they are generally placed within reasonable access to some town.

Probationer nurses are received for training from twenty-one years of age. They must be of good health and physique. A nurse who is successful in this branch of work should be able to obtain her certificate from the Medico Psychological Board at the end of three years' training. The salary is £19 the first year, with an annual increase of £1 up to £35. Free board, lodging, washing, medical attendance, are also supplied and uniform after three months' trial. The hours on duty are from 6 A.M. to 8 P.M., with two hours off for meals. Nurses get leave from 8 P.M. to 10 P.M. daily and one day weekly; they also have fourteen days' holiday after the first twelve months, increasing subsequently to three weeks a year.

The duties of the nurse in an asylum consist of the care of the patients, the supervision of the cleanliness of the wards and linen, and also of the work done by the patients in the various departments--the needleroom, laundry, kitchen, corridors, etc. It is obvious that in view of the number of patients, individual attention is practically impossible. Entertainments of all kinds are provided for the help and amusement of the patients, and nurses are expected to assist in arranging these. Consequently any one with a gift for music, acting, singing, or other accomplishment is an acquisition to the staff.

(2) _Registered Mental Hospitals_.--These, owing to their different circumstances, vary much in their conditions of service. Most of them are training-schools and receive probationers of good education, from twenty-two years of age, for a course of training. This consists of lectures by the Medical Staff and Matron, the subjects receiving most attention being Elementary Anatomy, Physiology, and Psychology; and there is, of course, practical training in the nursing of mental cases: in some hospitals a course of Massage and Swedish Drill are added in the fourth year.

Salaries are on the whole lower than in the County Asylums, beginning at anything from £15 rising to £19 in the third year with a bonus of £3 on passing the final examination of the Medico-Psychological Board. There must, however, be set against this lower rate of remuneration, the fact that these mental hospitals are often situated more centrally than the county asylums, thus making less expenditure necessary for travelling to and from the hospital when out on leave. The usual free board, lodging, washing, medical attendance, and uniform are also given after three months' satisfactory service.

The hours of duty are from 7 A.M. to 8 P.M. with two hours off for meals, etc. Leave during a month varies with the different hospitals, but is usually two whole days, three half days, four evenings from 6 P.M. to 10 P.M., and four evenings from 8 P.M. to 10 P.M.: there is also annual leave of fourteen days after the first twelve months, increasing to three weeks after three years' service.

The work in a mental hospital is totally different from that in large asylums. As there are fewer patients, individual treatment is the rule, and the nurse gets more intimate knowledge of her patients' condition, which she may thus do much to ameliorate. Owing to the homelike freedom allowed, nurses need to be specially patient and tactful. In return for this, however, by their much closer companionship with their patients they gain the opportunity of thoroughly knowing and therefore sympathising with and guiding them, and on this, successful treatment largely depends. The majority of the patients in these hospitals are suffering from acute forms of insanity, and this adds both to the strenuousness and to the interest of the nursing work: the fact that such patients frequently recover, acts as a great incentive to the work.

Private asylums are on a different basis and do not as a rule offer training.

A trained nurse may hope for promotion to posts as Sister of a ward, Night Superintendent, Assistant Matron, or Matron. These posts demand personal attributes in addition to good training--_e.g._, powers of organisation and administration, a knowledge of housekeeping, laundry work, etc. For the higher posts, training in general nursing is essential. In all forms of mental nursing it is undoubtedly a great advantage if the nurse has had a preliminary general training before entering on the special branch of the work.

The conditions for private mental cases are the same as those described under private nursing for general work (see page 184). The fees, however, compare very favourably with those obtained for general work, being almost universally higher. The great disadvantage is that the hours are very long and the work necessarily exhausting.

Much has been done of recent years to improve the conditions of service for workers in institutions, and there is still room for amelioration. Particularly is this so with regard to the long hours on duty and insufficient leave, due, chiefly, to shortage of staff. Increase is also urgently needed in the salaries in every department so that the nurses may be able to make provision for old age. When, as now, so many of them are dependent on a pension as the only provision for their old age, they are bound to stay at one institution for the whole or nearly the whole of their lives--an arrangement which is not to the benefit of either party, for "change is necessary to progress, and the tendency is, from long years of service in one place, to narrow and lose the adaptability of earlier years."

More arrangements are needed for the recreation of the nurses when off duty, especially in institutions situated in the country. Swimming baths would be a real boon; the beneficial effects of this form of exercise upon both nerves and body being too well known to need further comment. Its value also in promoting mutual helpfulness is by no means negligible. Reading-rooms, apart from the general common-room, are very valuable, as are also tennis courts where they can be arranged. All these, of course, mean expense, but, if the better class woman is to be attracted to the work, her interests must be considered. Moreover, healthful recreations, apart from their benefit to the nurse herself, must re-act favourably on the patients.

IX

NURSING IN THE COLONIES

Colonial nursing is usually undertaken by those who possess the spirit of adventure, and do not mind the prospect of pioneering work. Love of novelty, strong interest in fresh scenes and peoples, a desire to make more money than can in most cases be made in England, help a nurse in colonial work, provided that work really means her life, and she loves it. But let it be emphatically stated that the nurses who are _not_ wanted in the colonies, in any capacity, are those who are failures in their work in England, or who simply leave the dull work of the old country with the object of having a good time abroad. Such women may do immense harm in countries where it is essential to the Empire that English people should be looked up to with respect and admiration, and where almost the most important part of an English nurse's work (_quite_ the most important _if_ she is working in a hospital), is to make the native nurses, of whatever race they may happen to be, see the dignity and possibilities of their profession, and be stirred with the desire to become proficient themselves.

No special training is required for colonial work. A thorough all-round training, including midwifery, a high standard of nursing ethics, a knowledge of hospital organisation, and good business abilities are needed. The rest is chiefly a matter of temperament and constitution. It goes without saying that a nurse for foreign climates, whether tropical, as in the majority of colonial posts, or subject to extremes of heat and cold, such as in Canada, must be physically strong; she should also be of an even temper and philosophical disposition, easily adaptable to climate, conditions, circumstances, and racial peculiarities.

The nature of the work will vary greatly with the locality and the kind of post undertaken. The colonial nurse who does private work will find patients and their needs much the same all the world over; she must, however, be prepared for anything, and ready to make the best of all things in emergencies.

In tropical hospitals it is altogether another matter. If the nurse taking a Matron's post in such a hospital is the first European to have occupied that post, she will probably have every detail to organise and put in order, from providing dusters for use in the wards, to arranging off-duty time for the nurses. She will mostly likely see at once that everything wants altering, and yet she will have to "make haste slowly," _very_ slowly, or she will have everything in a ferment, and every one in open rebellion against her.

If she is working in the East, she will have the endless complications of caste and race and religion to deal with, and will have for some time, to learn vastly more than she teaches. Her success or failure will depend very largely upon how she gets on with the medical department--in other words, upon her own tact and common-sense, and whether she can so approve herself to the various medical officers that they will loyally back her up in her attempts at reform. Once things are established in working order, it is a question of constant supervision, day by day, for in no tropical hospital is it possible to expect that native nurses will do their work well and conscientiously, without the constant example and supervision of their trained Matron and Sisters.

Colonial posts are chiefly to be obtained through the Colonial Nursing Association, of which offices are at the Imperial Institute, South Kensington.

Salaries vary considerably, according to climate and the nature of the work. In very unhealthy climates, such as the west coast of Africa, the salary is high, and the risks proportionately so.

Private nurses, and those holding subordinate posts in hospitals get salaries varying from £60, which is the minimum, to £120 a year. An Assistant Matron may in some few cases get a salary increasing to £150 or £200. In a large hospital there is the ordinary chance of promotion--a Sister may be made Assistant Matron, or an Assistant Matron become Matron; but most colonial posts are simply for a certain term of years, at the expiration of which the nurse seeks fresh fields, her passage, both out and home, being paid. If, however, there should be a desire on both sides for a renewal of the engagement, the nurse can usually obtain an increase of salary.

A Matron's salary will vary from £100 to £250, in large Government hospitals in the Colonies where, it must be borne in mind, leave entails a journey to England, and a very expensive passage. In colonial posts there is usually six weeks leave yearly (which may be taken as three months together in the second year), but in most places there is no bracing climate within a reasonable distance. This, of course, does not apply to India and Ceylon, where the hills are easily accessible.

Each Government has its own arrangements with regard to pensions; some posts include pensions, but not all. The retiring age is usually sixty years. There is, unfortunately, no pension obtainable from the Colonial Nursing Association itself. This is certainly one respect in which it would be well if an alteration could be made; it is a question of funds and has already been brought forward for consideration. There would be vastly more inducement for really capable nurses, no longer very young (the age limit for joining is thirty-five) to join the Colonial Nursing Association, and serve their country in foreign dependencies, if they were assured of even a small pension after ten years' hard work in trying climates.

X

NURSING IN THE ARMY AND NAVY

The training required by Army and Navy nurses is that for general work. Additional experience according to the branch of the service which the nurse wishes to enter is also useful. Only fully trained nurses are appointed. Some of the tending of the sick is done by the men themselves, under supervision.

In the _Military Service_ the salaries are as follows: Matron-in-Chief, £305; ordinary Matron, from £75 to £150; Sister, from £50 to £65; Staff Nurse, from £40 to £45, with allowance for board, washing, etc., and arrangements for leave and pension after twenty years' service.

In the _Naval Service _the arrangements are slightly different, but the salaries work out at about the same. Foreign service is obligatory.

There is also a small Army Nursing Reserve, but this is quite inadequate for purposes of defence, and great efforts have recently been made to supplement it by voluntary organisations, such as the British Red Cross Society.

XI

PRISON NURSING

This is, at the present time, carried out by the ordinary staff of prison warders. There are all over England not more than two or three trained nurses among them, and it is most desirable that properly trained women should be in charge of prison infirmary wards, just as much as in the infirmary wards of workhouses. Prisoners are just as likely to suffer from disease as other people, and they surely do not forfeit all claim to expert care, simply because they have, perhaps in a moment of weakness, yielded to temptation. To one form of illness needing specially expert nursing, they are peculiarly liable--mental disease. It is almost impossible to gauge the amount of good which might be done both for the individual and for society by providing trained nurses to attend to these unfortunate people.

XII

MIDWIFERY AS A PROFESSION FOR WOMEN (OTHER THAN DOCTORS)

This is not a paper to discuss the suitability of women for midwifery. All through the ages it has been done by women, until early in the nineteenth century in England and its colonies, it gradually became customary for men-doctors to attend such cases; apart from this, the work of midwifery has never been in the hands of men, except when abnormal cases have required the assistance of a doctor with knowledge of anatomy and skilled in instrumental delivery. Even before the passing of the Midwives Act in 1902, statistics proved that three-quarters of all confinements in this country were attended by women.

Continental countries have been alive to the need for training the women who did this work. For instance, in the great General Hospital in Vienna with its 3,000 beds, 550 beds were kept apart for maternity wards, and of these, 200 were reserved for the State training of midwives--a course of _one_ year's duration being obligatory, with _daily_ lectures on every detail in midwifery from the Professor of Obstetrics. The present writer attended these lectures daily for six months in 1885, and was made to feel the importance in teaching of "hammering" at essentials and of questioning, so that the lecturer might discover whether he were talking above the head of the least clever of the audience.

England's population increased so steadily and rapidly during the nineteenth century, that it seemed to trouble no one that countless lives of mothers and babies were lost during the perils of child-birth; it remained the only civilised country of Europe where a woman could practise as a midwife without any training at all.

For nearly twenty years before the passing of the Midwives Act in 1902, a small band of devoted women laboured in season and out of season urging on Parliament the need of a bill requiring a _minimum_ of three months' theoretical and practical training and an examination before trusting a woman with the lives of mother and child.

This historical fact alone is a sufficiently cogent reason for the now ever-increasing demand on the part of women for the parliamentary vote.

The Central Midwives Board (C.M.B.), a body of eight members (experts elected by various bodies, such as the Royal Colleges of Physicians and Surgeons, the British Nurses' Association, the Midwives' Institute, etc.), now exercises supervision over the midwives of the whole of England and Wales, though local supervising authorities also take cognisance of midwives' work and investigate cases of malpractice and the like. The address of the Central Midwives' Board is Caxton House, Westminster.