As regards the saving her own time, strength, and securing her a
modicum of comfort in a work where, if she does her duty, she will
never have a superfluity of comfort. Time, strength, and this modicum
of comfort, enter much into a Nurse’s health--and health is essential
both for efficiency and economy.
Where the Nurse sleeps at a distance from her ward, her efficiency,
both as to superintendence and work, especially at night, in dangerous
cases, is seriously impaired.
If she sleeps at a distance from her ward, her comfort, also, such as
it is, is destroyed. Whatever a Nurse does for herself, she must do
by fits and starts. A really efficient Head Nurse is never able to
make anything for herself, though she often would far rather save the
money it costs to “put it out.” The most simple mendings, even the feat
of stowing away the laundress’ supply of a Saturday evening, become,
when a ward is heavy, or when there are two or three of those cases
of urgent danger, so many of which, by God’s blessing, the assiduous
care of these women saves, year by year, in our Hospitals, a procedure
done in several acts. The misery of dividing her small effects (the
smaller the better) between a day-room and a distant sleeping-room,
the unseemliness and inconvenience of carrying things backwards and
forwards, cannot be described.
If it be possible, the Nurses must sleep adjoining their wards; and it
will not do to give each only 24 patients.
It would be considerably better, if feasible, to have two Nurses in
contiguous rooms; but in the Pavilion Plan this would involve bringing
one Nurse away from her ward; and rather than this, the next best,
though inferior plan is to put one Nurse immediately above and below
the other, with a distinct bell which she can in a moment ring from
her bed into the other Nurse’s room, to summon her if needed.
[Sidenote: Importance of Lighting Hospital Wards by Gas, with Sanitary
Precautions.]
Some years ago gas was laid on in the Sisters’ rooms in Guy’s Hospital.
In the other Hospitals there is an allowance of candle to each
Sister. The disadvantages of gas are its alleged unhealthiness and
its certainly being disagreeable to some eyes. Its advantage is its
cheapness. Liberty to buy a candle and not use the gas is allowed at
Guy’s. As it will be a very important thing to conduct the Nursing
Service as economically as possible, and as there must not be any
wretched false economy as to essential matters, which in the end always
proves waste, it will be well to save as much as can be in matters not
essential. It would be worth while to ascertain the average amount
of saving which the substitution of gas for an allowance of candle
has effected at Guy’s. Gas is used in the wards of St. Bartholomew’s,
St. Thomas’s, and Guy’s, day and night. It appears, when ventilation
is properly attended to, to answer well, and to do no harm. At night
the gas is lowered so as to leave the ward just light enough to see
all that is done in it: if bleeding, &c. occurs, it can in an instant
be raised, and the ward lighted up. London Hospital burns gas in the
evening, and throughout the passages at night; but when the night watch
begins at nine, the wards are dark, except the Nurse’s candle. A spare
candle, un-lighted, is always at hand.
It is very important for the order of a ward that the attendant in
charge, and also any inspector suddenly entering, should see at once
all that is going on in the ward. Where there are dangerous cases, this
is of great moment; and where there are not, it is equally necessary
for the police of the ward. A candle or a rushlight give insufficient
light. Properly lowered, gas at night does not disturb the patients.
After a night or two, those who are accustomed to sleep in the dark get
used to it. If the Nurse sleeps adjoining the ward, there _must_ be
sufficient light in the ward at night. If the gas-fittings are properly
tight and if every gas-burner has a ventilator, so that the products
of combustion are effectually conveyed away, for each gas-jet consumes
as much air as eleven men, it would be greatly preferable that there
should be a low gas light in the wards at night.
[Sidenote: II.--1. Should it be necessary to serve one Pavilion with
one Nurse means by which this could be effected.]
II.--1. Suppose the Lariboisière plan retained, as proposed at
Aldershot, for a Military Hospital, with wards of twenty-four beds
each--then, with fear and trembling, but with the firm conviction
that it is better for human nature, most of all, for nursing human
nature, to have somewhat too much than a great deal too little to do,
I respectfully recommend that one Nurse serve the three wards of each
Pavilion.
One woman cannot sleep alone in the Pavilion. The Nurses must sleep
together near the Matron’s quarters. If the Nurses sleep away from
the wards there should be some way by which a Nurse can at once be
summoned, in case of any urgency in her ward, and it would be well
to consider this in the distribution of quarters. Either the Matron
should lock the Nurses’ quarters at night, and any summons should be
brought to her and by her referred to the Nurse; or the summons should
go straight to the Nurse’s door. There are difficulties both ways,
even supposing these summons should be unfrequent. The Nurse of each
Pavilion should inhabit the room on the ground-floor ward, where the
heaviest surgical cases will be probably placed, whence she can better
command the movements of the Pavilion, and attend the entrance of the
Surgeon.
[Sidenote: 2. Head Nurse’s Day in a Pavilion Hospital.]
2. Her day might be something like this (in time, perhaps, God will
bless us with some Army Chaplain who will get up early and give us a
very short service morning and evening):--
She should be effective, and enter the Pavilion about 6 A.M., go
through the wards, read prayers in one by turns at the appointed hour,
and give out the linen wanted. (Six is the nominal hour when the Head
Nurses of one great London Hospital enter on their duty.) Here must
be no nominal hours, all must be real, though not overstrained. Then
the dressings, &c., attendance on Surgeons, &c. With 72 patients on
different floors, she must train the Orderlies to do the lighter
dressings (by training I mean real teaching, not leaving the Orderly to
find them out himself); she must see all the wounds of all her wards
which she does not dress herself at least every other day (which she
can do by seeing some in the morning and some in the evening), and she
must dress the heavy cases of all the wards herself. All this, with
method, and not losing time by fetching and waiting, an efficient Head
Nurse can do.
She must be responsible for the linen of the wards; but this must be
simplified as much as can be, so as to secure responsibility, yet
relieve the Nurse of unnecessary time spent over it.
The Nurse should be relieved of all writing and counting, on the score
of loss of time incurred. It will not do to charge a Nurse, with
seventy-two patients on three different floors, with serving each man
his portion of diet; the diets of two wards would get cold while she
was serving the first. It will be better to make the Ward-Master of
Pavilion wards responsible for the serving the diets. There must, of
course, be a card at each bed, or some other record, showing the diet
the man is ordered. The Nurse must know at a moment’s glance what each
patient is ordered.
The largest London wards are the two male accident wards in the
London Hospital. Each Head Nurse has charge of five wards of 12 beds,
separated (and in some respects impeded) by two lobbies. Very often
there are fifteen beds in each ward (not by over crowding), and these
Head Nurses are often to be seen in charge of seventy-five patients
each, including many serious, and some urgent cases. The two lobbies,
the small wards, and the duty of some daily writing and arithmetic
in settling the diets, with some daily loss of time in fetching and
waiting for medicine, render a Head-Nurse’s service, as regards
“manual” labour, less efficient than it might be; even where she is
most efficient.
Relieve the Nurses as much as possible of all writing and arithmetic.
If it could be possible to relieve them altogether of the “settling”
the diets, so much, by a great deal, the better. In the Lariboisière
system, with one Nurse to each Pavilion, it is utterly impossible to
prevent the Nurse losing daily time and strength on the stairs. But,
relieved of writing, of arithmetic, of losing time by “settling” and
fetching, such women as it will be our aim to procure can get through
the duty of seventy-two patients, although with the serious drawback of
their being in separate wards and on separate floors.
If, however, the Pavilion plan were so modified as to have two
pavilions end to end, with an intervening staircase, so spacious and
well ventilated as to cut off the ventilation of the two wards on the
same plane, then all the conditions as to health, and facility of
nursing and supervision, would be much more easily obtained. Of this
more hereafter.
[Sidenote: 3. Responsibility of Nurse for Discipline of her Ward or
Wards--how Modified in Military Hospitals.]
3. As to the Nurse’s responsibility for the good order of the three
wards in a pavilion, supposing the three wards are served by one Nurse,
there must always be a clear difference between this responsibility
in the Head Nurse of a Civil and a Military Hospital. The Civil Head
Nurse, whose assistants are all Nurses, who with herself are under the
Matron, is charged with, and responsible for, the good order of the
ward, and it becomes her duty, the moment she finds herself unable to
do this alone, at once to call in the Steward, or equivalent Officer,
in whose hands is the police of the Hospital.
The Military Head-Nurse’s Assistants are Orderlies, _i. e._ men and
soldiers, who, with the patients, are under military discipline. Of
this military discipline, the military power from the Commandant down
to the Non-Commissioned Officers acting as Ward-Masters, &c., is in
charge; the duty of the Military Nurse is, I apprehend, in case of
any insubordination which she cannot put down at once, to call in the
Ward-Master or equivalent, before calling in the superior Military or
the Surgical Officer; it being, however, well understood on all sides,
that she has the right of direct appeal to the superior Military or
the Surgical Officer, if the Ward-Master does not do his duty, or
in the event of a grave irregularity, if he is not at hand, besides
its being her duty to report such to the Matron, if the case admits
of being deferred till that can be done. It is impossible to settle
details until the regulations as to the new Hospital Corps are fixed;
and whatever regulations, whether for Nurses or for Orderlies are
made, some difficulty, and much discretion will be inevitable and
necessary in working them. But it is necessary to bear in mind that
whereas in the Civil Hospital the Head Nurse, under the control of, and
responsible to, the Officers, including the Matron of the Hospital,
is solely in charge of both the nursing and the discipline of her
ward, both as to patients and as to Assistant Nurses; in the Military
Hospital, she is in charge of the nursing, and the Ward-Master of the
discipline, both of patients and Orderlies. To be in charge of the
nursing, implies to have power to enforce discipline, but this is
rather, in ordinary cases, to call in the military power, beginning
from the lowest or Ward-Master’s grade and reporting this to the
Matron, than to invoke herself the military superiors. Therefore it
would be well worth while trying how far it would answer to serve the
three wards by one Nurse, who, in each ward where she successively is,
is bound, on perceiving any irregularity, to call in the Ward-Master,
and, in contingencies, to appeal directly to the Surgeon and the
Captain of Orderlies, and to make the discipline of the three wards
the charge of the Ward-Master, who is bound to go through the wards
when the Nurse is not in them. The Ward-Master, in order to fulfil his
charge, must enter all the wards, while the Nurse is in one of them; so
that the patients of one ward, who may know that they are safe from the
Nurse for half an hour or more, as she is in another ward, know that
they are not safe from the Ward-Master.
In a military Hospital we must bear in mind that it is essential that
the discipline over patients and orderlies should be exercised by men,
and that the Ward-Masters must be the lowest and immediate deposits of
this power of discipline.
All these things must be settled with the concurrence of the
Director-General.
It is a great comfort that the Hospital staff returns to soldiers. We
shall get on infinitely better with them than we could have done with
the late Medical Staff Corps, though, after all, in the long run, we
should manage with them too. If only God helps us with the sort of
women required, thoroughly efficient Nurses, laborious active women,
discreet as well as well-conducted, and aware (a little) of the sort
of work and place, they are in!--let us trust this to Him, when the
time comes, and depend upon it, to give each Nurse plenty to do will
become one great means of forming such women--provided, which must be
strenuously kept in view, they are made to do it.
[Sidenote: 4. Importance of Lifts.]
4. It is very important to have the system of lifts throughout the
Hospital, although here, as throughout, the plan of Pavilions renders
them much more requisite, and makes them work less efficiently than
the block plan. Lifts, to carry meals and medicine, linen, coals, &c.,
&c., to and from the first and second floor wards, are very preferable
to the Orderlies carrying them up and down. One sort of load ought
certainly not to be brought up and down by lifts, but to be carried up
and down by men, viz., coffins and the dead. Using the lift for this
purpose (as is done in one Civil Hospital) is on all and every account
thoroughly objectionable.
The system of lifts is the more important, because although there is
no objection to the washing of tea cups, drinking cups, and medicine
vessels at the sink in the scullery, it is certainly neither necessary
nor safe to wash the dinner dishes close to the sick wards. By a little
arrangement, the whole of these could be removed by lifts to a scullery
beside the kitchen, and there cleansed and set aside for next day’s use.
[Sidenote: III.--1. Casualty Wards for noisy and offensive cases should
be separate from the ordinary Wards, and under a completely-appointed
Staff of their own--both for Sanitary and administrative reasons.]
III.--1. Sanitary necessities can never be interfered with. The
concentrating offensive and noisy cases together, while entirely
separating them from each other, in a completely appointed set of
wards, is a far more efficient working thing than appending a small
ward to each ward.
St. Thomas’s (a very admirable Hospital in very many things) has a
casualty ward (for such cases) for men and one, adjoining but separate,
for women, under the charge of one Sister. Baths are in the wards.
Guy’s had the same provision with, however, the drawback that there was
not a Sister in charge, but a Nurse over other Nurses, with higher pay,
but not a Sister or Head Nurse. However excellent such a Nurse may be,
every ward _must_ be under the same regular government as is general in
the Hospital, if discipline and order are not to suffer. Every ward or
set of wards should be under a completely appointed staff.
St. Bartholomew’s had a set of casualty wards, including two of about
ten beds each, several small wards of two and one bed each, including
two with gratings and other melancholy necessary appliances to prevent
extremely violent delirious patients from becoming suicides. These
wards were often partially empty, never quite so. They were long served
like the casualty wards of Guy’s; but some years ago they were placed
under the charge of the Sister of the male operation ward immediately
above, who received in consequence a small annual increase of wages.
London Hospital sent its noisome, offensive, and extra-infectious
cases to its other wards--small wards for one patient each, and, like
Guy’s, not under the regular management of a regular Head Nurse.
It most certainly appears that the plan of concentrating these cases
together, but with (as at St. Bartholomew’s) small wards where
extra-violent patients can be put separately, the whole under one staff
of Nurses, is far the best working plan.
And for this reason. Occasionally, a very offensive case requires
little nursing beyond the fixed daily dressings, and can lie quietly
enough in his bed or ward. But noisy cases almost always, and offensive
cases generally, require close watching. Now the moment we have a
patient in a little room at the end of the ward, it is our duty to
go in and out and see after him, and supposing him to be a violent,
delirious case, he is, unless under strong restraint, unsafe alone; and
even then the restraint requires looking to. In very many cases the
frequent inspection of Nurse and Orderlies would not be enough, and the
man ought to have a watcher.
We can never send one of the Orderlies of the ward, wanted for its
regular duty, to sit down in one of these little rooms; and we can
never keep a fixed extra Orderly idling about, unless the little ward
is inhabited. We must then fall back upon extra Orderlies, put in when
the case wants close watching--of course not otherwise.
At night, also, the watching which suffices for the ward will often not
suffice for the extra case--and he must have a watcher apart.
The plan of extra Orderlies or extra Nurses is a very bad one, to be
avoided as much and as long as possible; it very seriously interferes
with the discipline of wards.
Recollect that each offensive or extra-infectious case, put into the
little ward, ought to represent a great amount of separation and
care, which it will be difficult to secure. His mug, utensils of all
descriptions, bandages, &c., ought to be washed separately from those
of the patients of the large ward. Is this easily secured?
In the two Borough Hospitals they at once remove a case of erysipelas
or gangrene, occurring in any ward, erysipelas from venereal wards
included, into the casualty ward. In the two other great Hospitals
it is only when the erysipelas or gangrene becomes severe that the
removal is made. Now at once to remove these cases from the ordinary
wards is very advantageous.
St. Bartholomew’s larger wards for male and female casualty cases, two
small wards for two patients each, and two grated wards for one each,
are very efficient. The wards are all contiguous, and, as has been
said, under the charge of a remarkably efficient Sister, who has charge
also of the male operation ward immediately above. The little casualty
wards, of course, add to the work, and greatly to the anxiety of
watching; but certainly violent delirium tremens’ cases, alone and in
a secure ward which can be darkened, appear often to quiet much sooner
than where several of these wretches lie shouting to and at each other.
Delirium tremens will never be a thing unknown in a Military Hospital.
One such case in the little ward adjoining the Pavilion Ward would be
a heavy infliction on the severe cases in the latter; the noise would
be heard throughout it. And unless the ward were properly secured, or
unless the man were under strong restraint--and then that would require
constant looking to--he would not be safe a moment alone; while the
Orderly was emptying slops or bringing in his dinner, something might
occur.
[Sidenote: 2. Restraint or Non-restraint in Delirium Tremens.]
2. Restraint is again a thing which must be left to our masters, and
to them solely--but an ugly, sorrowful, little truth may here be told.
Restraining and non-restraining processes, and their results may be
seen, both where, in the same Hospital, one or more of the Surgeons
orders restraint never to be used to his patients, however violent, and
others order it to be used in violent cases: and where the rule of the
Hospital is to restrain violent cases, removing the restraint so soon
as the paroxysm is over, or as soon as amelioration renders the sudden
return of paroxysms less likely. I am not speaking of lunatic asylums,
but of delirium, particularly delirium tremens, in hospitals. Lunatics
occasionally enter the Civil Hospitals, but, of course, as soon as
that supreme earthly misery is ascertained, they are removed to the
proper refuge. It is my humble opinion and firm belief that mechanical
restraint excites a patient much less, and quiets him much sooner, than
the prolonged struggle with his attendant’s arms and hands, which
_must_ otherwise be resorted to.
The coercion apparatus ought also to be good, not cheap, and always in
perfect order. The least thing out of order either causes pain, which
when it can be avoided is cruel, or it endangers the efficiency of the
whole. The strength and cunning of these patients resembles those of
madmen, which for the time being they are.
Restraint renders the usual complement of ward servants able to manage
many cases. Non-restraint means that some person must stand or sit by
or upon the patient’s bed, and hold and struggle with him often for
hours--also that generally this person must be a stranger to the ward.
Extra attendants are most injurious to discipline. Could there be a
set of casualty or equivalent wards, with its own Head-Nurse, the sick
would gain much.
But if necessary to adopt the little ward with every ward--in that case
the Nurse must manage the three additional patients--twenty-four or
twenty-five are, indeed, too few.
[Sidenote: IV. Simplicity of Construction essential to Discipline.]
IV. In all Hospitals, let the construction be as simple as it can be.
Let its splendour be its lofty airy wards, with plenty of windows;
water in all due abundance on each floor; an ample, not excessive,
supply of linen, polished impervious walls and ceilings, well-laid and
bees-waxed oak floors, and a thorough not excessive, supply of good
apparatus of the various necessary kinds. But every _unneeded_ closet,
scullery, sink, lobby, represents both a place which must be cleaned,
and which must take hands and time to clean, and a hiding or skulking
place for patients or servants disposed to do wrong; and of such no
Hospital will ever be free. And every cornice, every brass lock or
handle, which could be replaced by a plain china or ebony one; every
decoration, or flourish, or ledge, on doors, windows, tables, beds,
presses, &c., represents either a collection of dust or a great waste
of hands, time, and strength in unnecessary cleaning and dusting. These
are not crotchets, but the result of close observation of the practical
working of these matters. Every five minutes wasted upon cleaning what
had better not have been there to be cleaned, is something taken from
and lost by the sick. Let the appurtenances of the wards be simple and
complete, but as plain and as undecorated as it is possible to be.
[Sidenote: Polished Walls.]
Polished impervious walls and ceilings are of the first consequence
in Hospitals. It is perhaps hardly necessary to state that, if Parian
cement be used, it must not and need not be of the kind lining the
wards and corridors at Guy’s Hospital, which is as rough as the
roughest plaster, of a dark and dirty colour, and which nothing could
improve but being lime-washed twice a-year; it should be polished like
that used at the Lariboisière Hospital at Paris, and of a pure white.
[Sidenote: Covered Exercising Place.]
In building a new Hospital, some covered arcade or some place where
the patients might take exercise in wet weather, and where inspection
could be exercised over them, without fuss, is worth contriving. In St.
Thomas’s, the patients walk under the covered arcades of the court.
[Sidenote: Reserve Wards.]
Both in Bethanien and in the Charité Hospitals at Berlin there are
reserve wards,--or rather in the Charité there is a reserve Hospital,
into which most of the sick are moved for six months in the year, to
change the air alternately of all the wards, which during the time
receive a thorough cleaning. Great stress is laid at Berlin on thus
providing, when building a new Hospital, a certain reserve space, which
obviates the necessity of less efficient and far more costly steps
afterwards.
[Sidenote: V. Nurses’ Meals.]
V. Let us, by all means, consider as settled, that the Nurses’ food is
sent them cooked. Possibly, in the long run, the undoubted advantages
of this plan will be found to be over-balanced by its disadvantages;
but let us begin by trying it. I submit that their dinners, and
possibly suppers, should alone be sent them cooked, and that each Nurse
should receive a fixed weekly quantity of groceries, and a daily or two
days’ allowance of bread.
For packing up the Nurse’s meals sent her from the kitchen, a Vienna
custom might be useful. Each Nurse to have a long, strong, straw
basket, properly named or numbered. Some contain five dishes and
covers, but two or three would here be sufficient for every purpose,
including an occasional slice of pudding. The dishes strong tin, with a
tin cover, and if the Nurse prefers eating her dinner out of it rather
than the dignity of plates, and the trouble of washing them up, the
Matron should let her take hers her own way. If taken by hand, two
baskets of this sort can be carried with ease. But if the Matron, as
a general procedure, sends each Nurse a hot little dinner, of a good
well-cooked portion of meat and vegetables, one such dish and cover
will do for one Nurse, and three, five, or six can be accommodated out
of the same basket, or one large basket, carried by two men, would
serve all the Nurses round. The dishes should, in either case, be
numbered or named, not the Nurse’s name, but the ward.
A dish and cover of strong, coarse earthenware is used in the Vienna
Hospital, as a grander edition of dinner, &c. The tin ones keep warm
without fire for a long time. If the meal arrives when the Nurse
cannot eat it, put by on the hob, or some provision for warming in the
scullery, it will keep warm and good till she can eat it.
[Sidenote: VI. Arrangements for a Pavilion served by one Nurse.]