II. Medical Officers who give fair play will find it impossible to
settle the matter, if, on ordering, _e. g._, leeches, the Orderly
shows Rule so and so by which he does it, and the Nurse Rule so and
so by which she does it. The existence of the old regulations and the
arrival of the new ones, about the Medical Staff Orderlies, were made
great use of against our work, by some of the Medical Officers, after
the heavy pressure of the war was over. So, at Scutari, a Principal
Medical Officer took away and would not restore the practice of the
nurses giving medicines, in which he was borne out by an existing rule.
Contradictory rules are miserable things.
Unless the Matron’s authority is supported by the Principal Medical
Officer the Patients always suffer. The Nurse is the only proper person
to be responsible for the directions of the Medical Officers being
carried out in a General Hospital.
III. It will enable the Matron to stop all nonsensical prudery, on
the part of the nurses, and to require that they should do what they
undertake to do, and not pass off to an Orderly, still less to a
patient, the duties they should discharge themselves.
As a general rule there is a good deal of this false modesty on the
part of Nurses, especially of Head Nurses. In individual cases it is
a serious thing to shake even false ideas of decorum: in laying down
general Rules it is the more important to lay down as duties what
are such. Suppose an application of what the French call “la petite
chirurgie” ordered. The Head Nurse “never dreams of doing such things.”
The Nurse, following her superior’s false shame of duty, transfers the
business to an ignorant patient. In some cases great harm has arisen
thereby to the Patient. In other cases, but not the majority, after
such an order given, the Head Nurse goes quietly to the bed, draws the
curtain round it, and makes the application herself--saying “she always
did that herself, as it was a business requiring care, as the patient
was often disposed to resist, and as she was thus certain that it was
properly and effectively done.” I have always admired and respected
such women; but they are not the majority. Very often patients are
allowed or left to do things for themselves, which they cannot do
properly, or when they ought not to be trusted to inflict the pain on
themselves which doing things properly often causes.
The practice of allowing some particular patient to become a sort of
half orderly in the ward, letting him always attend some particular
case, or give general help in severe cases, is most reprehensible. It
is never allowed, whether in Civil or in Military Hospitals, without
very bad consequences to the discipline of the ward. Where extra
help, in lifting, &c., is required, let the Nurse require the most
convalescent of the patients to help, but let her carefully refrain
from selecting any patient or allowing any patient to put himself
forward, as a regular help or quasi-Orderly. As an almost invariable
rule it will be found that the less patients do for each other the
better for themselves, and for the discipline and the good feeling of
the ward. Let them be made useful in the wards, as far as possible,
in such lighter cleaning, &c., as a patient can properly do (here,
again, discretion is required, or a lazy Orderly will lay undue
burdens on a willing patient); but the less they do for each other
undoubtedly the better for all parties. I would not, however, expressly
exempt the patients from being made useful in nursing the sick. A
lazy or ill-conditioned patient might make it a handle to refuse to
do or grumble at doing things which he ought to do, such as (a thing
frequently required) giving and emptying a bed-pan to an ordinary
patient who cannot leave his bed, while the Nurse and Orderlies
are doing other things in the ward; assisting to move a helpless
patient, if all the Orderlies are not at hand; sometimes watching or
attending for an hour or so a critical case, &c., &c., &c. What the
Superintendent-General and all Superintendents must be especially
vigilant against is selecting any particular patient or allowing a
willing patient constantly or often to do these things, and to become a
quasi-Orderly to the ward or to any patient in it.
Assistant-Surgeons, partly from inexperience and partly from spite,
sometimes make this sort of quasi-Orderly of a patient. The Nurse
should have the power of respectfully saying, in such a case, “The
Regulations order me to do so and so, sir: I beg you to let me do my
duty.”
It is an important and should be, if possible, an invariable rule that
no discharged patient is ever to enter any ward. Soldiers are, in
many respects, on a different footing, as to each other, from Civil
patients. The above provision is perhaps rendered thereby (not the
less, but) the more important for the good order of the ward. Still
this, desirable in (and the rule in several) Civil Hospitals, might
be considered by Military as well as Medical Officers to interfere
too much with the feeling of comradeship which, in its measure, is
so essential a part of the soldier’s very peculiar condition. The
following rules however might, at all events, be carried out. Some of
them are actually in the “Hospital Regulations.”
As quietness is indispensable in Hospitals, every duty should be
performed with the least possible noise, more especially at night.
Every patient must be in bed by 8 o’clock in winter, and 9 in summer;
and no conversation must be permitted after that time. Patients should
be made useful in the wards, as far as possible; but should fetch
nothing into them. And no discharged patient should be permitted to
enter any ward, except in the fixed visiting hours. The Governor, where
there is a Governor, or the Principal Medical Officer, will fix the
visiting hours; which shall not be more than two hours during each of
three days of the week. [Take proper advice as to whether this maximum
is too short. It is fully enough for Civil Hospitals, but Military
Hospitals are in sundry respects essentially different.]
In the discipline of all Military Hospitals, besides the prohibition
of all swearing and foul language included in the Articles of War, is
included the non-admission, or if by oversight admitted among visitors,
the immediate expulsion of all disorderly persons. (Query--whether not
to specify prostitutes.)
I very much wish that Hospital Sentries in General Hospitals might keep
out all visitors, except in the fixed visiting hours. And I very much
wish that a stringent rule were made as to female visitors, both in
Regimental and in General Hospitals. Proper Military as well as Medical
advice should be taken on this point. It might not do to exclude them
altogether; and, if soldiers’ wives come, it might be better to admit
also all respectable-looking women, for it would be useless attempting
defining as to sisters, aunts, friends, &c., &c.; though, except in
the case of dying patients, all women, except their wives and mothers,
are better away. I do not know what amount of strictness in practice
is shown in enforcing the Regulations in English Army Hospitals; but
if, at present, equivocal women, as well as ascertained prostitutes,
are not excluded (which very possibly they are) they should be. At
the same time, a sentry may often be honestly puzzled as to equivocal
or non-equivocal appearance, in these days of over-dressing. And some
mistake, made by a stupid or brutal sentry, might lead to endangering
the rule. This whole matter must be referred to men.
[Sidenote: 12. Orderlies’ Attendance.]
12. With regard to the question of the “Regulation” number of
Orderlies, viz., 1 to every 10 patients, it is to be observed,--
[Sidenote: (1.) 40-Bed Ward Minimum Size for Regulation Number of 1
Attendant to 10 Patients.]
(1.) A ward of 40 patients might be efficiently served (but it would be
hard work) with
1 Head Nurse--Female.
3 Orderlies.
With no number under 40 of patients to a ward, can the Regulation
proportion of 1 attendant to 10 patients be adhered to.
[Sidenote: (2.) 20-Bed Ward requires 3½ Attendants.]
(2.) With a ward of 20 patients (cut, scheme, and arrange the hours and
duties as you will), you cannot efficiently serve it with less than
½ Head-Nurse--Female.
3 Orderlies.
And the other ward of this Head Nurse ought to be on the same floor.
N. B.--The same number would quite as efficiently serve a ward of 25 or
even 30 patients.
[Sidenote: (3.) 10-Bed Ward cannot be served by 1 Orderly + ⅕ Nurse.]
(3.) The Army system of 1 Orderly to 10 patients, with a number not
exceeding 10 patients to a ward, is upset as immediately by one bad
case among the 10, as by 9 to the 10.
For, is the same Orderly to be on duty for the 24 hours?
The difficulty is practically got over by the Army, with a permission
that any “bad case” may select any one he likes of his comrades (out of
the Depôt) to be “told off,” to attend upon him.
This extraordinary regulation is equivalent to (and affords little
other practical result, than) granting opportunity for any quantity
of spirits, and illicit food, to be smuggled into Hospital, and it is
clear that it would be totally inadmissible in a General Hospital,
where the whole system of nursing would be under the most stringent
discipline and supervision.
[Sidenote: (4.) Female Nurses not to be Substitutes for Orderlies.]
(4.) The introduction of Female Nurses into Military Hospitals is not
intended to supply the place of Orderlies, but to perform a class of
duties which never has been performed at all in the Army. Few other
Hospital duties of those generally called such have been hitherto
fulfilled, in Military Hospitals, except
diet-carrying,
sweeping,
and writing.
[Sidenote: (5.) Naval Hospitals Regulation Number of Attendants 1 to 7
Patients.]
(5.) In all Naval Hospitals, the Regulation number of attendants is
1 to every 7 patients, or 2 attendants for each ward containing more
than 7 patients and up to 14. These Attendants or Nurses, in sailor’s
language, have charge of the linen, bedding, and ward furniture, under
the Ward Matron, and they are responsible for the proper care of the
sick, and the due administration of the medicine, wine, and other
medical comforts. They are on duty all day and watch at night in their
turn, which is regulated by the Medical Officer in charge of the ward,
in this or similar fashion:--a group of three contiguous wards is
allotted during the night to two nurses, one begins her duty at 9 and
ends at 1 o’clock, when she is relieved by another, who watches till
6. She patrols the three wards, resting in that one where there may be
a case requiring more than ordinary attention. If there should be a
case of fever, delirium, or other sharp seizure, extra Nurses, both men
and women, are assigned to the charge of that special case, according
to the urgency of its wants. The great majority of Naval patients are
either convalescent, or suffering from trivial complaints, which do not
impair their activity. They can therefore take care of themselves, and
assist the Nurse during the day in cleaning the wards, &c.--and we know
what good housemaids seamen make. The Nurses are paid one shilling a
night for night watching. They have under the most severe circumstances
two-and-a-half nights in bed for half a night out of bed.
At Haslar Naval Hospital the system of Orderlies, as understood from
the Principal Medical Officer, is as follows:--12 Orderlies are on a
floor, to look after, say, 90 patients. These are divided for night
duty into three divisions of 4 each; of these 4--
2 are on from 9 to 2, A. M.
2 ″ ″ 2 to 8.
The Head-Quarter room or ward is the one which has the most severe
cases; this ward, then, the Watcher at night sits in, and makes the
rounds of the others every now and then to see if anything is required.
This system will of course be modified, according to the nature of the
cases in Hospital. The other attendants do not sleep in the wards. The
Nurses are male or female according to the discretion of the Principal
Medical Officer.
[Sidenote: Civil Hospitals have even 9 Attendants to 44 Patients.]
In Civil Hospitals the number is as great of attendants to patients,
and is mainly determined by the size of the ward:
_E.g._, in one Hospital, where there are quadruple wards of 44
patients, 11 in each compartment, though the average number of patients
is 48, the number of attendants is 7.
In exceptional cases extra Night-Nurses, sometimes extra Day-Nurses
serve particular patients. The labour, both of cleaning and of
night-nursing, is much increased by the wards being four, separated by
a large lobby.
In another of the large London Hospitals, where there are to each ward,