[Sidenote: Nurse’s Room.]
It is essential that between every two wards, in a hospital where the
blocks are built end to end, there should be, as at the new Military
Hospital of Vincennes, a lobby with a thorough supply of pure fresh air.
If it were possible, where the Head Nurse, or rather in a Military
Hospital the Nurse, has charge of two such wards on the same floor, to
let her have a long, narrow room, with screened windows, opening into
both wards, the door opening into the passage in the midst, it is worth
contriving.
[Sidenote: Medical Officer’s Room.]
2. The Medical Officer’s room should be on the ground floor at the
entrance and apart from everything else.
The servant or whoever cleans the room, should not be a Ward-Orderly,
(ward-attendance cannot be kept too entirely separate from all other
concerns).
[Sidenote: Water-Closets.]
3. The ward water-closet should have a pane of glass at top, so that
a faint gas-light in the lavatory at night can light sufficiently the
closet, and the (bed-pan) sink.
The water-closet should be constructed, as is done often in those of
English railway stations, so that each visitor involuntarily, on rising
or on opening the door, purifies the concern.
Besides the ward water-closet, there should be general water-closets,
and urinals separate from the wards, for the use, during the day, of
those patients who can leave the wards.
The latrines at the Lariboisière Hospital are a good example, both for
what should be avoided in construction, and what should be imitated in
position.
The sort of latrine used there would never do for England.
The men able to go out are expected to use by day an urinal in a corner
of the little garden belonging to each pavilion.
At night no sick men are allowed to leave the ward on that or any other
pretence; they must use the latrines.
The latrines are at the furthest end of the ward. Opposite the one
door is a partially glazed door, beyond this is a large window, grated
in network as well as with panes and frame. On one side opens a space
where the men, able to get up, are expected to wash, and which,
moreover, contains two latrines, each separated by a partition and
secured by a door. The same arrangement prevails on the female side.
The rule of having the water-closet on the furthest side of the ward,
removing all pretence of leaving the ward by night, is excellent.
[Sidenote: Warm and Cold-Water Supply.]
4. The importance, immense addition of efficiency, and ultimate economy
of carrying warm and cold water into every ward, and the necessity
of intending and contriving this in the first construction of a
Hospital,--subsequent additions and alterations being generally less
effectual, and always more expensive--cannot too frequently be repeated.
[Sidenote: Corridors.]
5. Corridors as proposed at Netley are useful and objectionable. They
lie between one side of the wards and air. They make oversight of the
patients more difficult; and when a number of patients are walking up
and down them, the serious cases in the wards are disturbed. On the
other hand, it is desirable to have some place of exercise and yet
shelter for patients, capable of being heated and of being overlooked.
There ought to be no accumulation of patients at the same time suffered.
With regard, however, to corridors inside the building, if there
are none it is all the better for the sick; that each ward should
have two rows of large windows opening direct into the outer air is
indispensable, as has often been said already.
[Sidenote: Lobby.]
6. Provided this double range of windows be secured, double wards of
thirty on the same floor would cause no disadvantage to the sick.
But, if such be determined on, let especial care be taken to separate
the two, not by a showy hall, but by a lobby and an ample staircase,
extending from top to bottom of the building, and communicating freely
with the open air at the roof, as well as by the stair-windows:
admitting a thorough current of external air, so that, of a morning
especially, the two wards do not mutually send the close air into each
other.
The lobby should not be turned into a vestibule. Thorough air is all
that is wanted. Patients should not be suffered to remain in it.
[Sidenote: Material of Ward Utensils.]
7. The material of the different utensils required for ward service
should be settled. In the use of glass or earthenware for all
eating, drinking, and washing vessels there is great superiority as
to cleanliness, and the saving of time and labour in cleaning these
materials, to those of tin or other metal. Still two things have to be
weighed against these great advantages. First, if these vessels are
cleaned by Ward-Orderlies, the amount of breakage would be much greater
in proportion than as done by Nurses, and it is imperative to have as
few women as possible in the service of Military Hospitals. Secondly,
it is very important to avoid even the appearance, especially at first,
of anything like introducing luxury into Army Hospitals; and I can
quite understand this appearing like luxury.
The material of one description of ward-vessels should in particular be
left to the Surgeons. In sending to distant foreign or war-stations,
urinals of tin have one material advantage over those of glass or
china, that they do not break so easily; but, as to home-service,
these tin urinals cannot, by any amount of cleaning, be freed from an
unclean smell. In Vienna General Hospital, where economy is exceedingly
attended to, all the urinals are of glass, as the superior cleanliness
is considered well worth the additional expense. A damaged or broken
glass or earthenware urinal is dangerous; and if there is difficulty in
obtaining the immediate issue of a new for a damaged one, it is better
to have tin.
In Vienna General Hospitals the patients’ eating vessels were formerly
of tin; but were some time ago furnished of earthenware, for the same
reasons as those given above; also because the hot tin vessels were
found awkward to the patients. (I do not think much of this latter
reason; in hospitals, there is little fear of food reaching the
patients too hot). In Vienna and Berlin Military Hospitals the eating
vessels are all of tin.
[Sidenote: Reserve Wards.]
8. In building a large new Hospital, the question of whether or not
reserve wards, or Pavilions, should be provided is an important
question, to be referred to the proper Authorities. In one German
Hospital is a Sommer-Lazareth, or separate Hospital, which most of the
sick occupy during the six summer months. This is considered the best
plan; but so expensive that well-considered arrangements in designing
the building may render its adoption unnecessary. In another German
Hospital is a group of wards on each of two floors, into which the male
and female patients, especially the surgical cases, are successively
moved; both in order that during this time the other wards may be
thoroughly cleaned; also to change the air; also in case of some sudden
epidemic, &c.
In every Hospital a thorough cleaning of the wards is essential. In
three of the great London Hospitals this is done every year, in one
every three years. Nuisance as it is, for the time being, it is such
a complete purification of places which want purifying, that having
it done every year is preferable to every three years. For the same
reasons bare white walls, whitewashed every year, and oftener if there
has been some sudden outburst of any zymotic disease or Hospital
gangrene are preferable to all colour. But polished impervious cement
is, it is needless to repeat, the only really safe Hospital wall. When
the cleaning time of a great London Hospital draws near, the number
of patients is gradually reduced, and none but urgent cases taken in.
The cleaning usually begins with the topmost ward of one part of the
building, or of several parts of the building at once. The patients are
usually moved to the ward immediately beneath. The ward goes through a
complete purification, also reparation of whatever wants repair. All
its furniture ditto; the bedsteads in particular. Afterwards windows
and doors are left wide open for two or three days, and nights so
far as feasible. In about a week from its commencement the cleaning
is over; the patients moved back; and the ward or wards so cleaned
recommence their usual taking-in--and so on. The cleaning of a great
London Hospital usually takes two full months; and a great nuisance
it is for the time, but the place benefits by it the whole remaining
ten. It is excellent economy to have plenty of hands, so as to have
the cleaning part, in distinction to the airing part, done as quickly
as thorough cleaning admits of. It is very bad economy to put too much
of this great extra cleaning upon the Nurses. This would of course
not apply to a Military Hospital, where it is important the Orderlies
should become as thoroughly qualified as may be for foreign and war
service. It is necessary that whatever exterior help is called in,
should be closely overlooked; contractors and contractors’ servants
being seldom overmuch troubled with conscience.
Now it might be exceedingly worth while to have one or more reserve
Pavilions, with a view to this annual cleaning.
If the flooring of polished oiled boards should be found to answer
(that it should receive a fair trial is very desirable, as it might
result in a material benefit to our Hospitals), it would be doubly
useful, when, every third year or so, the oiling and polishing required
renewal, to leave the newly-oiled wards empty for a fortnight. An
additional week or two would additionally harden and improve the
flooring; but a fortnight would suffice.
It might also be right to have reserve wards for what must occur every
now and then in a Military Hospital, an influx of patients beyond the
usual number, or an outbreak of cholera, or some malignant epidemic,
which it might be desirable to isolate from the other patients.
It may now be confidently expected that, under the new _régime_, the
progress in improvement of Military Hospitals will proceed rapidly;
that it will be quietly done is almost as certain--real improvement
and noisy philanthropy being fearfully inconsistent with each other,
especially in that momentous machine called the Army of England, which
is no safe plaything.
Dr. Helm, the Director of the Vienna General Hospital, in a little
pamphlet published some time ago, insists on the importance, in
designing a new Hospital, of providing Reserve wards, especially with a
view to dangerous epidemics. They should admit, he urges, of easy and
complete isolation from all the remaining parts of the building.
[Sidenote: Occasional Revision of Rules.]
9. Dr. Esse, Director of the Charité, at Berlin, in a practical and
systematic, but pedantic and pudding-headed, little book on Hospitals,
published in 1857, strongly urges the importance of occasionally
revising and altering the rules of Hospital Officers and servants, and
all the Charité instructions end with this proviso of alteration. It is
one of our many unavoidable difficulties that it is necessary to begin
our work under definite rules, while it is also necessary to consider
the service, for some years to come, as tentative and experimental. It
is well to bear in mind what cannot be expressed.
[Sidenote: Defect in some Systems of Nursing.]
10. In admiring much, very much about the German Hospitals, it
becomes necessary not to omit a warning. A number of women, all equal
among themselves, with no female Superior or Superiors whatever,
under the sole control of men, in an ascending scale from the
Abtheilungs-Inspectoren or Oberkrankenpfleger, through Doctors of
sundry ranks, to the Director himself, such is the system followed,
as in the great Charité Hospital at Berlin, so in the great General
Hospital at Vienna; and this cardinal mistake leads to many others.
[Sidenote: Nurses’ Exercise.]
11. It is desirable that the Rules should give daily exercise to the
Nurses, or rather that the Rules should give them the right of daily
exercise; that the Superintendent should encourage and exhort them to
take fresh air daily when feasible, leaving them sometimes to take a
little quiet in their rooms. But in war service, and sundry foreign
stations in time of peace, not merely exigencies of service (which at
home will and ought often enough to curtail or abrogate exercise time),
but various other reasons might render it very undesirable to give the
Nurses right to two hours’ daily exercise. It must be impressed upon
all Superintendents, that it is essential in the long run to the health
of Nurses to have fresh air; but in many foreign stations it might be
far better for the Superintendent to take, or rather send, them out for
one _vice_ two hours, &c.
In war and foreign service, the exercise time must be at the discretion
of the Superintendent.
There may be awkwardness enough on sundry home stations in allowing
each Nurse two hours at her own discretion outside of the Hospital
every day. Still it is right to look things in the face. The Rules do
not contemplate a Sisterhood, but a staff of secular women, bound by
strict rules in all that concerns the duty they undertake, left to
themselves as to sundry things which in Sisterhoods are ruled. (How
and by what measures in process of time strong and quiet religious
influence may be brought to bear upon this staff, is the question of
vital importance as to the whole; without it, I doubt whether the
service of women would, in the long run, answer in Military Hospitals,
which are and must remain very peculiar places; with it, it might
please God to suffer good service to be done Him). Nurses trusted to do
their duty in wards must be trusted to walk out alone if they choose,
and I would not attempt to restrict it, though the Superintendent must
see to this, so far as she can without doing or encouraging spy-work,
a thing which has many advantages, and is often done in various, very
various ways, but which in the long run brings no blessing, and _pro
tanto_, degrades all who are concerned with it.
[Sidenote: Number of Ward-Masters.]
12. In Vienna Military Hospital each set of five or six wards, with 30
or 40 patients, sometimes 20, in each, had a Sergeant and a Corporal
over the Orderlies. (Berlin Military Hospital is served by Civil male
Nurses).
I think a Ward-Master would be enough for each Pavilion of six wards
of 30 patients each, in three stories, each couple of wards being in
charge of a Nurse, and each ward served by three Orderlies.