[Sidenote: 1. Lay down distinctly the communication which is to take
place between Director-General and Superintendent-General, and (in war
and abroad) Principal Medical Officer and Superintendent-General, and
the qualified subordination of the latter.]
1. In defining the office and duties of the Superintendent-General of
Nurses, her direct communication with, and qualified subordination to,
the Director-General of the Army Medical Department, and, abroad and
in war, with and to the Principal Medical Officer of the district,
or equivalent, must be very exactly defined. If the formation and
government of a body of women to serve in the Hospitals of the Army
Medical Department, and in these alone, is contemplated, the less
the Director-General and the Superintendent-General have to do with
each other, in matters of detail, the better, and the less chance of
collision. For very weighty moral and practical reasons, the sole
government of the women must belong to the Superintendent-General, and
to the Matrons, whom she delegates, and who are themselves responsible
and amenable to her. But it will never _work_ to introduce female
service into the Army Hospitals, and to leave the Director-General
of the Army Medical Department, which, like everything else in the
Army, is and must be a hierarchy, no other power in connection with
it, than to write and encourage confidential reports against it. There
ought to be a definition of the Superintendent-General’s position as
regards him, and also, as regards the Principal Medical Officer of the
district, abroad and in war. It is useless, and would be dangerous to
evade this; it ought to be deliberately settled, and distinctly stated.
In the “General Orders” of March 1856, the Superintendent-General’s
complete power over the women, and qualified subordination to the
Principal Medical Officer, are well and definitively expressed.
It is impossible to appoint the work of the Nurses without the
concurrence of the Director-General. It does not do to put a woman
into a great ward, or several smaller wards, of men, with several
orderlies, without clearly defining her position there. To put her
under the orderlies would be to make her being there at all much worse
than useless; but she cannot have assigned to her the responsibility of
the ward or wards, and consequently, authority over both orderlies and
patients, herself being responsible to the Surgeon and Matron, without
the concurrence of the Chief of the Army Medical Department.
Nor, without such concurrence, can the duties of the Nurses be
assigned. At this moment there are extant two sets of Regulations--the
old Army Hospital Regulations, and those of 1855 made for the late
Medical Staff Corps. In these Regulations, both the former and the
latter, every duty a Nurse can discharge is assigned to different
men. The responsibility of the ward, the administration of diets
and medicines, the application of poultices, fomentations, leeches,
enemas, and minor dressings, are all in so many words assigned as the
duties of Assistant-Surgeons, of Hospital-Serjeants, and Orderlies; and
of Assistant-Surgeons, of Ward-Masters and Orderlies of the Medical
Staff Corps. The Regulations in general are being revised;--so much
the better. But the new body of Orderlies, announced in the “Gazette”
as the Hospital Corps, will, of course, receive rules from the
Director-General; and if these things are not settled with him, there
will be contradictory rules in operation, which will most materially
thwart the working of the Female Service.
We have ourselves experienced this, as to the administration of
medicines, which one Principal Medical Officer took away from the
Nurses, saying that it was the duty of the Assistant-Surgeons, in which
he was borne out by an existing Regulation. And it would really seem as
if this were the intention of the said Regulation, for it is there laid
down that the medicines are to be administered twice-a-day, as if this
were a property of medicine.
The existence of these Regulations proved also a great stumbling-block
in the Castle Hospital, after the war-pressure was over.
Unless the Director-General, and in war and abroad, the Principal
Medical Officer, are brought into regular communication with the
Superintendent-General of Nurses, by the Rules, they will, at every
inspection of Hospitals, revert to the procedure of giving orders
and making alterations, which in fact amount to reprimands on the
Superintendent-General, and on her Matrons, through the medium of some
Clerk or Orderly. There should be, therefore, a distinct channel of
communication laid down between the Director-General, and in war and
abroad, the Principal Medical Officer and the Superintendent-General of
Nurses.
[Sidenote: 2. Also between Principal Medical Officer and Matron,
Staff-Surgeons and Matron, Staff-Surgeons and Nurses, and the qualified
subordination of the Matron and Nurses.]
2. Also, and in the same way, there should be distinct rules for direct
communication between the Principal Medical Officer of each Hospital,
and the Matron, and between the Staff (or equivalent) Surgeons of the
Hospital, and the Matron; if not also between these latter and the
Nurses.
The constitution of a General Hospital is about to be organized in
England. In the large War Hospitals there was the Principal Medical
Officer, a Staff-Surgeon in charge of each Division, then the
Assistant-Surgeon, who answered to what, as is now proposed, is called
the Prescribing Medical Officer of the Wards. As regards the Matrons
and Nurses, it must not be proposed to ignore all but these Prescribing
Medical Officers. Certainly, it would never do to give the Superior
Surgeons of the Hospital no _say_ as to the nursing. In 999 cases out
of 1,000, the Superior and older Surgeon is the one who understands and
cares much the most about the men, and who, therefore, in the long run,
would more appreciate and be fairer to Matrons and Nurses who did their
duty by them. The Superior and older Surgeons too, in general, have
far more correct ideas of the importance of discipline in a ward, and
of the ways of maintaining it, than the Assistant-Surgeons. Moreover,
as far as one can judge on a mysterious subject, generally speaking,
the older and Superior Surgeon is the honester man. He must be brought
into direct communication with the Matron; this will effect good, and
prevent mischief. So also let the Staff-Surgeon of the Division, or
equivalent, be placed in direct communication with the Nurses of the
wards of his Division; this will effect good and prevent mischief. If
the Nurse is to trust to receiving the orders of the Staff-Surgeon,
through the medium of the Assistant-Surgeon, she will often find
herself in a false position.
[Sidenote: 3. All the General Hospitals cannot be undertaken at once.
(The material of Head-nurses to be created.) Secretary of State
should be made aware that the Female Service can only be introduced
gradually. Director-General must have a voice in the introduction.
Director-General and Superintendent-General differing, Secretary of
State to decide.]
3. Now, as to the introduction of Nurses into all General
Hospitals--this gets rid of many difficulties, but at a fearful cost.
For years to come, the difficulty will be not to extend the work,
but to serve such Hospitals as must be undertaken, with respectable
and efficient women. The material has, in a great degree, to be
created; abundance of applications will be received--the prospect
of a pension alone will do that--but the real choice will be very
limited. In these Military Hospitals each Nurse must be a Head Nurse,
and a trustworthy woman. Many a woman who will make a respectable and
efficient Assistant-Nurse under the eye of a vigilant Head-Nurse,
will not do at all when put in a military ward or wards, herself the
only woman, and Head-Nurse over the Orderlies. As a body, the mass
of Assistant-Nurses are too low in moral principle, and too flighty
in manner, to make any use of here. Supposing all the Head-Nurses of
the great Civil Hospitals[5] offered themselves, there are perhaps
not many who could be recommended for a _Military_ Hospital. Some,
who are very highly to be thought of, would never bear transplanting
into the _res dura et_ servitii _novitas_ of the Army Hospitals.
The class from which the Head-Nurses are mainly drawn, tradesmen’s
and servants’ widows, &c., will volunteer in numbers, but, in the
majority of cases, intending only to lead the idle life of many a
London Head-Nurse--“mental, not manual labour”--“Superintendence”--
_i. e._, standing by while the Orderlies do her work and their own.
The material has to be created. The rarest powers can do nothing
effective in this, in 3, 6, or 12 months. To lay a solid foundation
will take the patient, anxious labour of years. To begin with one
Hospital would have great advantages. Netley, if it is proceeded with,
might be the one, though, in most respects, a Hospital in an ordinary
vulgar seaport would be far preferable. Then let the work gradually be
extended. It is much more to be feared that the line will be taken of
forcing prematurely than of opposing its extension. If it is attempted
to occupy all the General Hospitals at once, how is the gratuitous
repetition to be avoided of the inevitable misfortune of Scutari,
viz., that of beginning on a large scale, with a number of strangers?
It certainly should be left to the Director-General to regulate the
introduction of Nurses into the General Hospitals--and there is far
more reason to fear that he, if unfavourable to the change, will
hurry, than obstruct such introduction; indeed it might be better to
settle that matter beforehand with the Secretary of State, letting
the Director-General be apprised of it, viz., that time is required to
effect the gradual introduction of the Female Service with which the
Superintendent-General has been charged.
To sum up. A rule must be introduced by which the Director-General
is brought into communication with the Superintendent-General, and
her qualified subordination to him distinctly expressed. Let the
Principal Medical Officer in war also communicate directly with the
Superintendent-General or the person performing her functions in the
War-Hospitals, and her qualified subordination to him be distinctly
expressed. The same with each Principal Medical Officer of a Hospital,
and the Matron of that Hospital. No alteration in these Regulations
can, of course, be made without the consent of the Secretary of State.
In case the Director-General and Superintendent-General finally differ
as to any new arrangements, the matter should be referred to the
Secretary of State.
The Superintendent-General should issue special regulations for nurses,
after conference with the Director-General, and under the sanction
of the Secretary of State; also, local regulations for the Matrons
with the consent of the Principal Medical Officer and sanction of the
Governor of any General Hospital.
If the Matron differ with the Principal Medical Officer, the decision
should rest with the Governor of the Hospital.