“I believe, from a long experience of hospitals and other
institutions, that the cost of an improved system of nursing as
proposed for the Liverpool Workhouse Hospital would certainly be ‘in
part’ repaid by restoring the patients to health more quickly.”
2. _Copy of a Letter from_ Miss Jones, _Lady Superintendent of St.
John’s House Nursing Schools, and Matron of King’s College
Hospital_.
King’s College Hospital, _May 4, 1864_.
Dear Sir,
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.