Part 2

The inclosed paper was sent to me yesterday, with the request that I would obtain from some of the medical staff of this Hospital answers to the question proposed at the end of the paper, in order to enable the Vestry in some degree to judge whether that body would be justified, or otherwise, in sanctioning the introduction to their Workhouse Hospital of an improved system of nursing the sick, at the probable annual money cost named in the inclosed paper.

I have accordingly submitted the paper to as many of the medical staff as I could see in the short time.

I inclose a note from Mr. Henry Smith, one of the surgeons, who has had considerable experience as to the loss and gain of good and bad nursing.

Dr. Wm. O. Priestly, the Physician Accoucheur to this Hospital, formerly of Middlesex Hospital, had not time during his visit to do more than read the paper and give me a verbal answer. He said, “I have no hesitation in saying that the saving would be certain and great.”

The Assistant Physician Accoucheur, who has until last week had charge of the medical patients here, as House Physician (Mr. H. L. Kempthorne), says, “The value of trained efficient nursing cannot be overrated in the management of acute diseases, and especially fevers, and would speak for itself in the saving of life, humanly speaking.

“In chronic cases, the eye of the trained nurse would soon detect the malingerer, and thus save the parish the expense of maintaining one who could well keep himself.

“In the prevention and amelioration of disease this plan would soon show its importance in the effects of cleanliness, ventilation, and other points carried out systematically and intelligently.

“The moral influence of the trained nurses by precept and example must in time diffuse itself through the medium of the pauper nurses to the paupers in hospital, the workhouse, and thence to the parish at large.”

I regret my inability to obtain fuller testimony to-day, but professional men are busy, and their visits to the hospital only on stated days.

If I can be of further use in any way, pray command me.

I am, Sir, Very faithfully yours, (Signed) M. J. _Superintendent of St. John’s._

After collecting and considering all the information within their reach, the Sub-Committee reported as follows:—

The Sub-Committee appointed on the 14th ultimo to consider and report as to a suggested alteration in the Staff of the Workhouse Hospital, report,

That the superiority, as nurses, of trained, experienced, and responsible women to the pauper women upon whom, under the present system, the actual nursing of the sick inmates of the workhouse devolves, is so apparent, that they conceive it to be unnecessary to offer any further observations upon this part of the subject. The points which have mainly occupied your Committee’s attention are the following:—

1. The cost of introducing a staff of trained nurses into the Workhouse Hospital, or any portion thereof. 2. The practicability of providing sufficient accommodation in the Workhouse for such an increase of officers. 3. The supply of trained nurses.

1. Your Committee are of opinion that the substitution throughout the Workhouse Hospital of trained nurses, for the present pauper nurses, would involve a direct expenditure of from 2,000_l._ to 2,500_l._ per annum. Should it be decided, in the first instance, to introduce the nurses into the male hospital only, it is probable that a sum of 800_l._ per annum would be found sufficient for the purpose. Evidence has been laid before the Committee to show that in those hospitals where the improved system of nursing has been introduced, the increased cost thereof has been more than compensated for by the saving, from the reduction of the time during which the patients are under treatment—the effect, as is alleged, of good and efficient nursing. Whilst your Committee admit the force of the argument, that if this be so in the case of hospitals, where the sick only are burdens upon the funds of the institution, much more must it be so in the case of the parish, where, as often happens, the whole family are chargeable upon the rates in consequence of the sickness of its head; they think it necessary to point out that one great difference between the workhouse hospital and an ordinary infirmary consists in this, that while in the latter (as a rule) none but acute and supposed curable cases are admitted, the former is, in many cases, the refuge of those who, as incurables, cannot gain admittance to other asylums. There can, however, be no doubt that the saving resulting from the rapidity and completeness of the cures effected by good nursing, will be a considerable set-off against the increased cost of the nursing staff; though your Committee can offer no decided opinion as to the probable extent of the saving so effected.

2. Your Committee believe that accommodation equal at least, if not superior, to that afforded to the nurses in the London hospitals, can be provided in the Workhouse at a moderate outlay. It is estimated that, for the male hospital, a sum of from 400_l._ to 500_l._ would suffice to provide the rooms and to furnish them.

3. With reference to the supply of suitable nurses, your Committee have to report that, as the authorities of the Nightingale Training School for nurses have offered to render to the Select Vestry all the assistance in their power in obtaining trained nurses, no great difficulty on this point need be apprehended.

Were your Committee as sanguine as some of the hospital authorities whom they have consulted, as to the happy results to be expected from the introduction of trained nurses into the Workhouse, they would at once, with the utmost confidence, recommend that the whole of the hospital should, at the cost of the parish, be supplied with this class of officers; but, looking upon it as they do, as an experiment (at least in its economical results), they unanimously recommend that the system should, in the first instance, be tried in the male hospital.

J. W. CROPPER, _Chairman_.

_May 5, 1864._

The report of the Sub-Committee met with the approval of the Vestry. Some delay in the adoption of its recommendations was caused by a severe outbreak of fever in the town, which for the time absorbed all the resources of the Vestry and its officers. But on the 18th of May, 1865, a Lady Superintendent who had received a thorough training at Kaiserswerth and St. Thomas’s, twelve Nightingale nurses from St. Thomas’s, eighteen probationers, and fifty-two of the old pauper nurses were placed in charge of the patients in the male wards of the Workhouse Infirmary. By the judicious management of Mr. Carr, the most admirable arrangements were made for the accommodation of the nurses. Each superior nurse had a little room to herself, and the ex-pauper nurses were entirely separated from the other inmates of the Workhouse. It was hoped that by taking the best of the able-bodied inmates, separating them from the other paupers, and paying them small wages (say 5_l._ a year) they might be made available as assistant nurses, and that many of them might be elevated into independence and usefulness. It will be seen from the foregoing report of the Governor (p. 10), that he always distrusted this part of the plan adopted; and after the system had been at work a year, this attempt to utilize pauper nurses in a workhouse hospital was found to have utterly failed. It was proved that in a town like Liverpool, with very few exceptions, those able-bodied women only become inmates of the Workhouse who are either tainted in character, or are exceptionally ill-educated and inefficient. The experiment, however, was not wholly useless. It conclusively established two facts: that such women are utterly unfit to be trusted as nurses; and that their employment in that capacity does not effect all the saving that might be supposed. It might be thought that the choice lay between such employment and maintaining the pauper in idleness, while paying a nurse in her stead. But it was found—as the Governor had always predicted—that when sent back from the hospital to the able-bodied wards, nearly the whole of these women left the Workhouse, and relieved the parish from the charge of their maintenance. Many of these women, when employed as nurses, remain in the Workhouse for the sake of what they can pick up or extort. And moreover, when they left it, the training they had received, such as it was, rendered them more intelligent, and perhaps not more unreliable nurses than those usually employed by the poor. It is not unlikely that in country places the unfitness of able-bodied paupers to become assistant nurses may be far less than it has been found to be in a great seaport town like Liverpool. They may probably be less universally tainted in character, and after a year or two of employment as under-nurses they may be able to maintain themselves in that capacity out-of-doors, thus not only relieving the parish of their own maintenance, but assisting to diminish sickness and pauperism among their neighbours. The point is one which must be left to local knowledge and experience. It might be well, however, not to promise them payment till after some length of probationary service. It was always after pay-day that the ex-pauper nurses were most liable to get drunk and misbehave.[4] With the exception of the failure of the nurses taken from the pauper class, the first year’s trial was sufficiently successful to induce a continuance of the experiment. It was impossible, however, to judge the result by statistics. None that were available could be considered as an evidence of success or failure, for several reasons. The season was very unhealthy, and to relieve the pressure on the space and resources of the hospital, steps were taken to treat slight cases outside, as will be seen from the following extract from the Minutes of the Finance Committee, 24th November, 1865:—

“The district medical officers, Dr. Gee, Mr. Barnes, and the Governor of the workhouse being in attendance, pursuant to resolution of the Workhouse Committee at its meeting yesterday, the practicability of limiting the admissions to the Workhouse Hospital was considered, and the district medical officers were requested to co-operate with the relieving officers in limiting such admissions to those cases that cannot be properly treated outside the Workhouse.”

The endeavour to limit the admissions to serious cases would of course affect the returns, both as regards the time taken in curing, and the proportion of deaths. Even had there been no exceptional disturbing element, there is a defect in the statistics of workhouse hospitals which affects all inferences from them, in the absence of any careful classified list of cases kept by the medical officers, such as might fairly enable one to form a judgment from mere statistical tables. These, then, are not reliable as means of judgment, unless extending over a long period. The character of seasons, and nature of cases admitted, varies so much from year to year as to invalidate any deductions, unless founded on complete and minutely kept medical records. The following extracts, however, from the reports of the Governor, and the surgical and medical officers of the Workhouse, bear decisive witness to the value of the “new system,” especially as contrasted with the “old system,” which in 1865-66 still prevailed in the female wards. All these reports bear emphatic testimony to the merits and devotion of the Lady Superintendent and her staff. The medical men, it is noteworthy, speak strongly of the better discipline and far greater obedience to their orders observable where the trained nurses are employed—a point the more important because it is that on which, before experience has reassured them, medical and other authorities have often been most doubtful.

_From the Report of the Governor._

Thursday, _May 10, 1866_.

The main feature in the new system of nursing consists in the superseding of pauper nurses, and appointing in their places competent trained nurses from the Nightingale School. These latter to have the assistance of “probationary nurses,” or in other words, women of intelligence and of good character desirous of entering upon the duties of nursing the sick as a profession. A third class was also created, designated “Assistants.” These were selected from the old pauper nurses, and it was decided that they should be paid, clothed, and receive rations equal in quality and quantity to those issued to the officers of the workhouse. The nurses, probationers, and assistants were placed under the control of a “Lady Superintendent,” who was empowered to employ them in the manner to her seeming best for the proper care of the sick.

The Committee will be prepared to hear that the change was immediately followed by the most marked improvement in every respect. The most casual observer could not avoid perceiving it. This applies not only to the state of the wards, the care of the sick, but is particularly observable in the demeanour of the patients, upon whom the humanizing influences of a body of women of character, devotedly discharging their duties, has produced evident fruits.

The question has often been asked whether the “new system is likely to succeed?” The “old system” meant nothing more than this, that old, ignorant, and unreliable pauper women, many of whom were of doubtful character, were entrusted with the discharge, without pay, of responsible duties. These have been displaced, and active, intelligent, reliable women, trained and skilled as nurses, with good characters and pay, have been appointed to supersede them. It would be a great discredit if these latter did not discharge their duties incomparably better than the former could do. That they do so I am happy to be in a position to testify.

In the opening paragraph of this report it is stated that “assistant nurses” were appointed and placed upon pay from the ranks of the paupers. This I was always opposed to. Their employment has resulted in complete failure, as the following figures will prove. The total number appointed to this date is 141. Of these sixty-seven have been dismissed through drunkenness and other misconduct, and sixteen have resigned; while it is positively true that there is not one of the whole number to whom I could entrust the duties of serving out wine or other stimulants, or, in fact, any duty requiring the exercise of integrity.

The experience of the past year renders it certain that the Poor Law, as now existing, offers no impediments to the successful working out of the most complete scheme for the efficient nursing of the sick, in the manner advocated by the best friends of hospital nursing.

(Signed) GEO. CARR.

_From the Report of_ Robert Gee, Esq. M.D. _Physician to the Workhouse Hospital_.

5, Abercromby Square, Liverpool, _May 10, 1866_.

Sir,

In the medical wards of a general hospital the cases vary so much in nature and degree from year to year, as to render it impossible to give a reliable statistical comparison of the value of a paid as distinguished from an unpaid staff of nurses. I am, therefore, necessarily compelled to report in general terms on the nursing of the last ten months in the male medical wards; premising that what I say in approbation of the new system, and the new staff of nurses must not be construed as an unfavourable reflection on the _whole_ of the previous staff. The paid superintending nurses of departments, and a few of the unpaid pauper nurses, deserve great credit for their conduct, though their qualifications for the service were decidedly inferior to those of the trained “Nightingale” staff.

With regard to the latter I can cordially bear testimony to their ability, and to their unwearied and uniformly kind attention to the patients under their charge. As to their nursing in its specific sense, I may state my belief that in every case my directions and those of the House Surgeons have been rigidly carried out. The medicines, stimulants, &c. &c. have been carefully administered, and the other numerous but less agreeable duties have been faithfully and efficiently attended to. Under their charge I have perceived a marked improvement in the demeanour of the patients—in fact, the discipline of the wards is completely changed. There has been no disorder or irregularity, but a sense of comfort, order, and quiet pervades the whole department. I believe further, that every patient leaving the wards has been more or less morally elevated during his location there.

_From the Report of_ J. H. Barnes, Esq., _Surgeon_.

_March 21, 1866._

Since my connexion with the hospital last August we have had somewhat approaching a hundred operations, many of them of a serious and dangerous character, requiring not only prompt assistance at the time, but most persevering attention night and day for a long time after. Almost all these operations have been in the male hospital, and I have no hesitation in saying that what success has attended them has been greatly owing to the most efficient assistance rendered by the trained nurses; and from my experience of the assistance received from the pauper nurses, in the few cases of operation performed in the female hospital, I should feel great diffidence in undertaking on that side such operations as I have had on the other side: indeed on one or two occasions the pauper nurses ran away, and when induced to assist were so nervous and frightened as to be of little service.

Without any wish to speak harshly of the unpaid nurses employed on the female side of the hospital (who, I believe, strive to do their best, more especially since a feeling of emulation has been set up by the introduction of the paid trained nurses, of whom they are jealous), I am compelled to state my conviction that on that side my directions are not carried out with that necessary promptitude and skill that they are on the other side, and that in all I do there I feel as if I were working with blunted instruments. There is no want of inclination, but simply a want of ability. That _integrity of disposition, promptitude of action, tact in manipulation, gentleness of demeanour and kindly consideration_ necessary to make a nurse are not found, or _to be_ found in the inmates of a workhouse, and no amount of education can work out of them what never was in them. Almost always obtuse, and too often unprincipled, as a class they are thoroughly unreliable, and quite unfitted to take charge of the sick and helpless, or the stimulants necessary for them. On this last point I have been informed by a former resident surgeon that he has known the pauper nurses appropriate the patient’s stimulants, or withhold giving to a dying patient that ordered for him, that they might take it themselves after his death. It is difficult to bring home and prove these things, and I do not wish to say they now occur, but if we wish to put such conduct out of the region of possibility it can only be done by the employment of persons superior to the temptation so to act.

Persons of one class, as a rule, favour their own class, and there is a far better chance of double-dealers being detected when under the observation and care of a trained nurse, than when under the care of one of themselves. That such is the case my own experience testifies.

As far, therefore, as my experience extends of the system of trained nurses, whether regarding the saving of life, the restoration to health, or the relief of the suffering, it has been an undoubted success.

These reports were duly considered by the authorities; and after some discussion, it was resolved entirely to discontinue, in the male hospital ward, the employment of paupers as assistant nurses, and to substitute an additional number of probationers. A Sub-Committee of the Workhouse Committee was appointed to superintend and report upon the working of the system. These gentlemen devoted much time and attention to the subject, and at the close of the year undertook a minute inquiry into the operation of the old and new systems; examining personally the various officers of the Workhouse, from the Governor down to the pauper nurses in the female wards. Increased experience brought out in a yet stronger light the superior advantages of the employment of trained nurses. The very able, clear, and conclusive report of the Sub-Committee leaves little more to be said on the subject. It determined the Vestry to adopt the system in permanence, and to extend it to the whole of the Workhouse Infirmary, a year before the period fixed for the trial of the experiment had expired. It will be seen that the report of the second year’s experience has a peculiar value, as bearing on the question whether, or how far, women may be competent to undertake one of the most delicate and difficult kinds of feminine work—one requiring special knowledge as well as special habits of punctual regularity, obedience, and thoughtfulness—without receiving any special training or education for such a duty. If the reforms about to be introduced into the pauper hospitals in London and elsewhere are not to end in failure and disappointment, provision must be made for training the nurses to be employed there, either before they enter the hospitals or within them.

The report of the Sub-Committee of Superintendence is as follows:—

The Special Committee on Nursing, pursuant to resolution of the Workhouse Committee of the 7th of March instant, report,

That the Men’s Hospital (exclusive of fever patients) is at present exclusively nursed by skilled, _i. e._ specially trained nurses and paid assistants, who are themselves undergoing training as nurses; the staff consisting of the Superintendent, nine of the nurses originally sent from the Nightingale School, five nurses who have been trained in the Workhouse, and fifteen probationary or assistant nurses.

Of the character of the nursing in this portion of the Workhouse, your Committee have heard but one opinion. The Governor and the Medical Officers concur in speaking of it in terms of the highest praise, and throughout the whole period during which the Committee have superintended it, no single circumstance has come to their knowledge calculated to make them speak of it otherwise than in terms of approval.