4. (And under the Governor) the proposed Superintendent of Nurses
and her nursing staff.
There is no reason why all these parts of the machine should not
work together.
The funds are provided to pay the extra nursing for a time.
The difficulty is to find the Lady to govern it.
When appointed, she must be authorized—indeed appointed—by the
Guardians. She must be their Officer; and must be invested by the
Governor with authority to superintend her Nurses in conformity
with regulations to be agreed upon.
So far, I see no more difficulty than there was in settling our
relations as Nurses to the government officials in the Crimean
War.
The cases are somewhat similar.
As to the funds, it is just possible that eventually the Guardians
might take all the cost on themselves, as soon as they saw the
great advantages and economy of good nursing.
If Liverpool succeeds, the system is quite sure to extend itself.
The Fever Hospital is one of the Workhouse Infirmaries. That is
the place to shew what skilful nursing can do. The patients are
not all paupers. How many families might be rescued from pauperism
by saving the lives of their heads, and by helping the
hard-working to more speedy convalescence!
Hopefully yours,
(Signed) FLORENCE NIGHTINGALE.
_Extract from a letter from the_ Right Honourable Sir John M^cNeill,
G.C.B., _dated Granton House, Edinburgh, 28th Feb., 1864_.
There can be no doubt, I think, that it would be a mistake to have
pauper nurses mixed up with paid nurses, and I think I expressed
that opinion when we conversed about those things. Paupers might,
however, be employed to scrub and to do other menial work, under
the orders of the paid nurses. If the paid nurses are to do much
good they must have a recognised authority in their wards. Without
authority there cannot be due responsibility, and things must get
into confusion. A nurse carrying out the instructions of the
medical officer must have authority to do so, and resistance to
that authority must be treated as a breach of discipline.
To put this upon a right footing from the first, would be
indispensable to success. The more a nurse does by influence, and
kindly influence, the better; but dealing with the promiscuous
inmates of a workhouse, the knowledge that there is authority in
reserve to be exercised if necessary, prevents the necessity of
resorting to it, and makes the patients duly appreciate the
kindness which keeps it in reserve.
With regard to all such matters, a great deal will depend upon the
good-will, the good sense, and good feeling of the Governor and
Matron, but especially of the Governor. He can do much to promote
or to mar the success of the experiment, and so can the medical
men; but if they be men of sense and right feeling, they cannot
fail to perceive how vast an addition to their own comfort the
permanent establishment of such a system as you propose to
introduce experimentally, must produce.
The position of a medical man dependent for the execution of his
instructions upon nurses who are neither intelligent nor
trustworthy, is very painful, and tends to deteriorate his own
character, both as a man and as a practitioner, by rendering him
callous to preventible suffering which he is denied the proper
means of relieving, and by compelling him to forego the use of
remedies which require intelligence and conscientious care in
administering them. The house Governor, if he be a conscientious
man, must be kept in continual anxiety about the conduct of
ignorant, and often worthless pauper nurses in the hospital, and
is driven at length to be satisfied with a low moral and
intellectual standard in the nurses, and a corresponding standard
of care and comfort in the hospital.
The Select Vestry took the subject into their serious consideration,
and instituted most careful inquiries in various quarters. Among
other steps, they called for a report on the probable operation of
the proposed system from Mr. Carr, the Governor of the Workhouse.
That report ran as follows:—
_Extract from the Journal of the Governor of the Workhouse._
Liverpool, Thursday, _April 14, 1864_.
In compliance with the instructions of the Workhouse Committee, I
have carefully considered the proposal made to the Committee by a
Liverpool gentleman, on the subject of nursing the sick in the
Workhouse Hospital, and beg in reference thereto to report—
That, practically, the proposal amounts to this—that there shall
not be any pauper nurses in the hospital, but that there shall be
appointed in lieu a staff of duly qualified paid nurses and
servants, with a head superintendent, under whom the whole of the
nursing of the sick shall be conducted on the best known
principles.
This proposal rests its claim to favourable consideration on the
presumption that the present system of nursing the sick in the
Workhouse Hospital is defective. The Committee are aware what that
system is. It may thus be briefly stated. Certain wards of the
workhouse are set apart as hospital wards. They do not form an
hospital worked as a whole, but are divided into five portions,
each forming a distinct set of wards, in close proximity to the
wards of the healthy paupers, and in five different parts of the
workhouse. These five sets of wards I shall call the Workhouse
Hospital. The hospital is divided into eleven sections. At the
head of each section there is an intelligent paid superintendent
nurse, and under each such superintendent nurse there is placed a
staff of pauper nurses, with the aid of whom she is required to
work her division, according to certain rules and regulations made
and provided for that purpose. A copy of these rules is appended
hereto; from which it will be seen that the burden of the
responsibility of carrying out the orders of the medical officers,
devolves upon the head nurses or superintendents of divisions. The
pauper nurses clean up the wards, carry the food, and give general
assistance to the superintendent—the duties of nursing in detail,
that is to say, the bedside nursing, falling chiefly upon them.
They are not permitted, however, to serve any patient with
stimulants, beer, porter, or medicines requiring exactness or
care; all such duties are discharged by the superintendent nurse.
The proposal now made to the Committee, means that the paid staff
shall be increased, so that the sick shall be cared for by
responsible officers only, and not left, even partially, to the
care of pauper nurses.
There is no doubt that pauper nurses are unreliable, inefficient,
and many of them very worthless; and it is only by careful
watching, and the utmost stringency of regulations, that they can
be made serviceable in the hospital. No stringency of regulations,
however, could guard against the most flagrant abuses, if these
women were employed to discharge duties of trust, such as serving
out the stimulants, &c. so that their services in attending upon
the sick are limited and common-place. There is therefore, in my
mind, no doubt, and I cannot see how any doubt can exist, that to
remove these women, and appoint in their places women of
character, trained as nurses, will tend to improve the position of
the sick, and more rapidly restore many of them to health.
To displace these pauper women, however, involves a complete
change in all the hospital arrangements, and suggests the
difficulty of finding and keeping up a supply of suitable nurses
to undertake the work at, as it would no doubt often happen, short
notice. The Committee are aware, too, that owing to the fact that
the paupers have hitherto been required to attend upon the sick,
the accommodation for paid officers is very limited, and that the
adoption of the proposal would render it necessary at once to
provide additional rooms for the additional staff. The Committee
are also aware that the Workhouse Hospital differs from other
hospitals in this—that it forms a part only of a mixed
establishment, and that there are great difficulties to be
overcome in completely cutting off every connexion or species of
intercourse between the hospital departments and the healthy
inmates, without which the scheme under consideration could hardly
succeed. If any good is to result from the adoption of this
proposal, the sick should be placed absolutely and entirely in the
hands of a paid staff, without the assistance, in any form, of any
one of the pauper inmates. Cut off the hospital department from
the healthy wards; and do not, under any pretext, suffer
communication between the sick and the healthy, and you strike at
the root of every species of workhouse abuse; but if, under any
pretext, you suffer a large number of healthy paupers to pass
daily into the sick departments, as they now do, the adoption of
the proposal will effect little good.
But the question has to be still further investigated on the
ground of expense; and it has to be decided the number, pay,
allowances, and accommodation of the necessary staff to work it
out. Now, although I entertain very strong opinions as to the
undesirability of employing paupers to discharge responsible
duties of any kind, because to do so destroys the value of the
workhouse test, and tends to reconcile them to pauperism; and
although I view the particular work of nurse-tending as the very
worst kind of work for paupers, inasmuch as, while so employed,
they are better fed, have more freedom of action than they
otherwise would, and can make their places emolumental—thereby
holding out a positive inducement to pauperism; and although I
have no doubt that the displacement of these women would be
followed by the immediate application for discharges by a large
per-centage of them; and although, at this moment, many other
weighty considerations press upon me in favour of the immediate
adoption of the proposal under consideration, I feel unwilling, in
view of the difficulties to be overcome, some of which I have
indicated, to incur the weighty responsibility of recommending
such a course on my own unaided judgment. I have abstained,
therefore, from taking up the question of expense, &c. but take
the liberty respectfully to suggest, that a sub-committee be
appointed to report upon the whole question in all its details. It
shall be my anxious desire and pleasure to assist the labours of
such sub-committee by every means in my power.
According to the recommendation of Mr. Carr, a Sub-Committee was
appointed, consisting of men of great experience in parochial
business, who went up to London, and had interviews with the medical
and other officers of the two metropolitan hospitals where nursing
has been brought to the greatest perfection—St. Thomas’s and King’s
College Hospitals. Finding that some of these gentlemen wished for
more information respecting the Workhouse Hospital system before
they would venture to express decided opinions as to the economical
results of the proposed reform, the Liverpool Visitors drew up a
statement on several points affecting this question, with written
inquiries, to which answers were returned, verbally or in writing,
by the gentlemen consulted. This statement, with the replies which
it elicited, is here given at length:—[2]