CHAPTER III.
The Hospital Ward
It is in the hospital ward that the major portion of routine hospital work is accomplished, and where the nurses who will have much of the responsibility of the hospital work of the future will be trained in habits of accuracy and neatness, in proper systems of ward work and good hospital housekeeping. Inasmuch as the number of hospital officers varies with the size and demands of the hospital, it should be understood that for the purposes of these papers the hospital housekeeper combines the position of superintendent of nurses and matron—the plan that is generally conceded to be productive of the greatest degree of harmony. In all but small hospitals, competent assistants in both the nursing and domestic departments will be needed, but the authority and responsibility of affairs domestic should be centered in one woman. Whatever may be the opinion of hospital trustees on that point, no one who has lived for a year in a hospital where the superintendent of nurses and the matron were equal in authority, and pulling in opposite directions, will sigh for a repetition of the experience.
The architecture of the hospital ward, and the general plans of the building, will have not a little influence in creating difficulties for the housekeeper and in adding to, or lessening, the burdens of the nursing staff.
Tiled floors and walls are ideal for wards, but too expensive for every hospital to have. Even five feet of tiling on ward walls is greatly to be desired. Denied that luxury, as many hospitals are, the next best thing is to have the walls finished in cement or hard plaster, which, if well coated with enamel paint, will admit of thorough cleansing and disinfection.
Heavy moulding and sharp corners which afford a lodging place for dust and germs should not be there. The ceilings should be high, and ample air-space provided for the number of patients for which the ward is designed. The ventilating shafts, windows and radiators should be arranged with reference to the proposed location of the ward beds. When the hospital housekeeper can manage it, each ward will have its own linen room, with abundance of linen. It adds no small item to the number of miles a nurse is obliged to walk each day, if every time she needs a clean sheet, towel or gown she has to walk half the length or the whole length of a long hall to get it.
A little forethought and consideration for the nurse’s part in the hospital economy, in arranging the plans of the building, would result in at least avoiding unnecessary labor for those who will have no small part in carrying out the humane designs of the hospital.
Soiled Clothing
Of equal importance is it to have a “clothes chute” on every floor, connecting with the sorting room in the basement. This will render unnecessary large receptacles for soiled linen. The storing of quantities of soiled bed and body linen in the vicinity of the hospital ward for even a few hours can never be anything else but injurious. The atmosphere cannot be pure while soiled linen is there to give off its impure odors. Very dirty linen should be rolled in a separate bundle. Pins should be removed and disinfection attended to before being sent to the laundry. Clothing belonging to patients should be plainly marked with the owner’s name. In most cases it will prove more satisfactory to all concerned for the hospital to decline to be responsible for laundering articles of personal wear for any patient. There is always danger of their being lost or torn.
Buying Beds
The ward beds should be of uniform height and style and well coated with enamel paint. In buying beds several important points are to be considered. If beds are offered which require two men, and a hammer, and a box of bolts and a wrench, to get them adjusted, they should not be considered, even if listed at a dollar each. They are dear at any price, when one considers the prices that prevail in the labor market, the strain on human patience, and the fuss that the moving of such a bed to another room or ward entails. It is a mistake, too, to buy beds without inquiring the length. Six-foot patients are not uncommon, and these find it very distressing when put in a bed that is too short. The bed should be at least six feet four inches in length.
In all hospital beds, there should be some kind of bar at the foot, that will keep the mattress from slipping down. Some hospitals have attempted to remedy this defect in beds by having boards sawed and placed as foot boards, but these are unsightly, and if the right kind of bed is bought such makeshifts will not be necessary. Before ordering a quantity of beds, it is well to get a trial bed, and thus be sure of the quality of mesh in the wire mattress, and that other details are satisfactory. No beds without back rests should be purchased, for in the majority of cases a back rest will be necessary. Separate back rests must be purchased and stored when not in use, and these are rarely as satisfactory as when attached to the bed.
It is well, also, to look closely into the plan of the back rest. Some have a round iron rod across the lower edge If such a thing is there, a sensitive, nervous patient will discover that rod, and worry till she or it is removed.
In ordering beds it is wise always to state the height from the ground that is desired, or low beds may be sent. About twenty-four or twenty-six inches is the usual height desired. It is possible to secure beds that can be adjusted to any desired height. The disadvantage of such beds is the difficulty of adjustment so that each corner will be exactly as high as the other corners. Each one must be measured, and the moving of the wire mattress up and down on the legs of the bed, makes it impossible to keep the enamel on the legs.
By all means hospital beds should have castors, and care should be exercised to see that these castors are so constructed and adjusted that they will not fall out every time the bed is moved. There is a great difference in castors and in their durability.
For the general wear and tear of a hospital, the cotton-felt mattress is giving better satisfaction than the hair mattress, and it is somewhat less expensive. It is a good plan to have a few pads made of bed ticking thickly inlaid with cotton batting. These should be made the same size as the bed, with rings at the corners to secure them. For very filthy or unconscious patients these pads are desirable, as they can be washed and boiled as often as necessary. A couple of these pads makes a bed as comfortable as a mattress.
Bed Making
The mattress should be carefully protected by a rubber sheet securely fastened at the corners. Every nurse thinks she knows how to make a bed before she goes to a hospital for training, but as a matter of fact very few do. It is sometimes a difficult thing for the nurse to learn, but it is one of the most important of the early lessons in ward work. The appearance of the ward beds, and the way in which they are made, is a good index to the character of the nurse in charge. If the spread is on crooked, the open ends of the pillow covers pointing in opposite directions, and the bed has the loose appearance of having been thrown together without method, one may naturally expect the general work of the nurse to be slipshod and unreliable. It is well to teach nurses to stand at the ward door occasionally, and take a critical survey of the ward, noting down the things out of order. A nurse who is watchful in observing signs of disorder in her ward may naturally be expected to be a careful observer of signs of disease.
Order, which is said to be Heaven’s first law, should be one of the first laws of ward work. Even the height of the curtains of the windows add to or detract from the appearance of the ward. The beds should be an equal distance apart and in a straight line. The head of the bed should never be used as a drying-place for wash cloths or towels, nor as a hook on which to hang bath robes and wrappers.
Ward Lockers
Aseptic ward tables of iron and glass are now being used in some hospitals, but it is doubtful if their use will ever be general. They answer some of the purposes of a ward table, but not all. Even very poor patients prefer to have their own combs and toilet articles, their own handkerchiefs and stationery, their own books and flowers. If some place is not provided for these numerous small things, which the average patients find it necessary to have close by, they will inevitably resort to stowing their “things” under the mattress—a custom not to be tolerated by the neat housekeeper. Good housekeeping requires that in a hospital, as elsewhere, a place be provided for everything and everything be kept in its place. Until the proper aseptic ward table is invented and offered at a reasonable price, the small wooden locker, well coated inside and out with enamel paint, will continue to be used. These lockers can be made to order for a very moderate price, usually from three to five dollars each. They should be about 20 inches in width, 30 inches from the floor, 14 inches deep, and mounted on castors. The drawer should be about 4 inches deep and there should be a shelf in the lower part. A daily inspection of bedside lockers is necessary, or apple cores, fruit peelings, remnants of food, and refuse of various kinds will accumulate. All cupboards and linen rooms should have daily attention, and should be in such perfect order that the doors may be thrown open at any time for inspection without embarrassing the nurse in charge.
Care of Patient’s Clothing
The outer garments of the patient and those not needed during illness should be taken charge of by the nurse on the entrance of the patient, and the list recorded in a book provided for the purpose in every ward. Each article should be labelled, and placed in the locker in the general clothes room, and the number of the locker noted with the list of clothing in the record book. An accurate and uniform system of clothes records throughout the hospital should be insisted on. Unless this is done confusion when the nurses’ places are changed will be inevitable. Carelessness in this duty on the part of a nurse has resulted in no small discomfiture to the hospital officers. Clothing has been mislaid and not found for weeks after the patient has left the hospital, and the whole institution has been branded with negligence by the patient and his friends. All the kindness received, and the most skillful professional treatment, will often be lost sight of, if, through the carelessness of a nurse, the hospital is unable to render to the patient the clothing entrusted for safe-keeping. Money or valuables should never be kept either in private room or hospital ward, but sent to the office to be deposited in the safe.
Ward Medicine and Records
Though many well-regulated hospitals have a medicine cabinet in every ward, the custom does not generally prevail, nor is it desirable that it should. The less a patient knows, sees or thinks of medicine, except the dose intended for him at the time, the better. The custom of hanging clinical records over the foot or at the head of the bed is another custom that might better be abandoned, even though it be very convenient for the nurse. Patients are only too prone to meditate upon and discuss their symptoms, in spite of all efforts to induce them to trust themselves entirely to doctors and nurses, and cease questioning and worry. Some sympathizing friend or convalescent patient may be depended upon to keep them informed when an unpleasant symptom is recorded. This will occur in spite of all rules and vigilance. It is not easy under any circumstances to keep ward patients from discussing their ailments and symptoms. Especially is this true in women’s wards. In men’s wards the newspapers are read, the political situation is discussed, city improvements and occurrences are talked about, all sorts of subjects occupy the time of those who are able to talk, but a different state of things entirely prevails in the women’s wards. What they get to eat, how they feel, and the nurses and doctors furnish the general topics there. To have a clinical record to gossip about might divert attention from the nurses and doctors, but even these long-suffering individuals would willingly sacrifice themselves as a topic of conversation rather than have the patients read the records and constantly discuss their symptoms.
Adjuncts to the Hospital Ward
The tendency in modern hospitals is in favor of smaller wards, as affording better facilities for proper classification and separation of patients. A nurses’ utility room adjoining every large ward or located conveniently near two or three small wards, where medicines, clinical records, supply charts and blanks, order books and the memorandum books necessary for ward work are kept, is a much appreciated convenience in some hospitals. Opening off this room is the ward diet kitchen, where the refrigerator and food supplies for the ward are kept, and the facilities for quick preparation of special diets for individual patients.
Quiet Room
A much needed adjunct to a hospital ward is an isolation or “quiet” room, to which a patient whose presence is offensive to the other occupants of the ward may be removed. Whenever possible, a dying patient should be separated from the other patients in the ward. Gruesome tales that are disgraceful have been told of patients passing out of life in full view of the other occupants of the ward, without even the measure of privacy a screen affords. It is a melancholy comfort to relatives and friends to be with the patient in his last hours, and this cannot be permitted in a ward without confusion and discomfort to other patients. When planning a ward for the care of the sick or the poor, the object, of course, is the saving of lives, but people will die in hospitals in spite of the best skill and care, and the poor man is surely entitled to a quiet place to die in. There is much in hospital life to blunt the sensibilities of those who live in such institutions constantly. Familiarity with suffering and death robs them of mystery and awe, but it should never be allowed to detract from the reverent care of the dying and dead. “Put yourself in his place,” is a good rule to observe in dealing with even the most unworthy of Adam’s sons.
Matters Miscellaneous
The ease with which the routine work of the ward goes on will depend largely on proper facilities and a proper system. There should be a regular order for the work of the day—a time for bed making, a time for sweeping and dusting and washing the ward floors, a time for the daily cleaning of the bath rooms and toilet rooms and refrigerators and cupboards. Interruptions may be expected, but unless a routine order of work is established the cleaning will be executed in haphazard style. Neither nurses nor maids can be depended on to use their judgment in such matters. If left to plan their work, they will probably be found sweeping their wards when the doctors are ready to begin their dressings, and the time for other things will depend on their ideas of the importance of the various duties. The habit of doing things quickly and thoroughly should be formed by every one who has any responsibility of the routine work of a hospital, where everything should move with clock-work precision. So much time can be wasted by lack of system, or in talking or dawdling. The untidy habit of leaving glasses or utensils dirty till a sufficient quantity has accumulated to make it a necessity to wash them, should never be tolerated.
It ought not to be necessary to mention the necessity of plenty of tools and the right kind of tools for ward work—plenty of basins, and syringes, and dressing pans, and instruments, and drinking-cups, and medicine glasses, and the thousand and one little things that go to make up the complete furnishings of the hospital ward. But, as a matter of fact, many nurses go through their course of training hampered by a lack of facilities for proper work. One set of instruments for dressing is provided, where several are needed at the same time; insufficient linen to keep the beds and their occupants clean is the rule, and so on indefinitely.
Destruction of Appliances
On the other hand, head nurses and hospital housekeepers lament over the carelessness of nurses and the constant destruction of hospital appliances. Just what course to pursue with the girl who every few days puts a rubber catheter or rectal tube or nozzle on to boil, and lets it burn up; who pours boiling drinks into glass tumblers, and thereby keeps up a constant breakage; who leaves hypodermic needles without wires, and finds them useless when needed again; who breaks medicine glasses and fails to report the accident, till the head nurse finds her measuring medicine with a spoon; who puts the thermometer into the mouths of delirious patients or children, and goes away and forgets it; who lets the sterilizer boil dry; who puts glass syringes and appliances in unsafe places, and returns to find them broken—just what course to pursue to correct these destructive tendencies is an ever-recurring problem to the hospital housekeeper. Nurses who are most careful and conscientious in carrying out the doctor’s orders, and in their duties to the patients, frequently lack that fine sense of honor regarding their duty to the hospital and the care of materials. A deposit for breakage is now demanded in some hospitals when a nurse enters for training. If this is not done the nurse should be made to replace articles destroyed and to pay for repairs that are rendered necessary by her carelessness.
Proper economy in the use of hospital goods is an important lesson for nurses to learn early in their career, and one which will demand frequent emphasis throughout their course. Gas stoves are left burning when not in use, and help to swell the gas bill. Milk is left out of the ice-box, and quickly becomes unfit for use. Materials of various kinds that could be utilized are thrown away. The destruction or waste of one article seems a very trivial affair, but in the aggregate such trivial affairs amount to hundreds of dollars in the course of a year. The cost of rubber sheets alone is an important item in ward expenses. The best will soon crack if folded when not in use. If loops of tape are fastened to the corners and the sheets hung against a closet wall when not in use, they will be found to last twice as long.
Screens
Plenty of screens in a hospital ward is a necessity to proper nursing. The poor appreciate privacy and refinement and delicacy as much as many of their wealthier neighbors, and they have a right to such privacy as a screen affords. The timid, frightened little woman who has just been admitted, and who shrinks from the gaze of everybody, ought to be screened off till the first awful feeling of strangeness wears away. The patient who is critically ill needs also to be screened. The general work of the ward requires the constant use of screens. One screen for every two beds is not too many for the necessities of the average ward. One of the most practical and altogether desirable ward screens is made of a wooden frame, white enameled, covered on both sides with white oilcloth. A set of clothes-bars, from four and a half to five feet high, makes a very satisfactory frame, that is large and yet light enough for one nurse to handle.
A fair equipment for a ward of twenty beds would be: