CHAPTER III
Salary—Increase of Salary—Carfare—Transportation—Telephone—Vacation—Sick-Leave—Uniforms—Badges.
Salary. A good nurse should command a good salary—she is worth it. There is a tendency to underpay nurses even at the present day, because of the tradition handed down from the Middle Ages, that nursing service should be given largely as a matter of love or charity. A woman who gives up her whole time to district nursing, doing highly specialized work, should at the very least receive a living wage. Associations are often asked to supply nurses at a salary of forty or fifty dollars a month, and surprise and indignation have been expressed because such a woman was not forthcoming. Salaries should be large enough to attract and retain efficient women; a small salary does not attract desirable applicants, as a rule, and this limits the field of selection. Large sums are appropriated for hospitals, sanatoriums, dispensaries, and physicians’ services, but retrenchment takes place when it comes to the nurse. Her work seems to be the one point where economy prevails.
In Baltimore, the staff nurses are paid seventy-five dollars a month, and this is the very least that any woman should receive. A small town or country community would doubtless have to pay more than this, especially if it looks to the city for an experienced nurse. The reason is simple enough—other things being equal and the character of work the same, one would hardly expect a nurse to prefer an unknown locality, away from home and friends, unless some extra inducement were offered. A nurse might be willing to organize work in a small city, at a low salary, for the sake of the experience. In that case, it is the experience which offers the inducement. This once gained, however, she would shortly be in a position to demand more salary or seek a wider field of service.
Increase of Salary. The question constantly arises whether or not it is well to increase the salary of the staff nurse from year to year. If she enters the work at seventy-five dollars a month for the first year, is it well to increase this to eighty dollars a month for the second year, eighty-five dollars the third, and so on till a definite maximum has been reached? To this question there are two answers.
Undoubtedly a nurse becomes more valuable as her experience ripens. Her first six months on duty are largely spent merely in acquiring rudimentary knowledge concerning her work. As she learns to know her district, her patients, the doctors, the institutions, the social workers, her value to the community increases. Each succeeding year, therefore, which increases her knowledge of social conditions, should make her in so far more valuable. It would seem but just, under these conditions, that her remuneration should be raised accordingly. But at this point there enters a factor which we must recognize. To specialize in tuberculosis work makes peculiar demands upon one’s strength. Quite apart from the physical strain, which is always great, it demands the expenditure of a vast amount of nervous force, required in the constant combat with opposition. For this reason it is peculiarly wearing and exhausting. Also, by its nature, it tends to become monotonous. These two factors—one of which tends to wear out the individual, the other to make her indifferent and stale—make us hesitate to say that the nurse’s value keeps increasing year after year. It undoubtedly does increase up to a certain point, but after that point has been reached, it tends to diminish. Such being the case, the obligation of raising the salary is debatable.
Two kinds of nurses are usually found on the staff. One is the ambitious nurse, who comes for the experience and training, to fit herself for an executive position elsewhere. To such a woman, the routine of field work will not be desirable for long—not for more than a year or two, or until she has gained enough experience to prepare herself for a wider field of service. That point being reached, her executive ability will seek an outlet in work where she herself may become the organizing and directing force. To such a nurse, salary increase will offer no inducement, since she will seek that increase through work which provides greater opportunities and responsibilities.
There is another sort of nurse on the staff however, who has no such ambition; no executive ability, no desire to occupy any other than a subordinate position. This one will never venture into a position of responsibility, such as her experience might warrant, but prefers instead the easier path, choosing to be guided rather than to guide. She prefers to work under direction, rather than to direct others. To such, an increase in salary would seem but a just reward for faithful service. But, as we have said before, the monotony of tuberculosis work tends to produce stale workers. There is danger, after a time, that the first alertness and energy may wear off, the nurse may settle down into a rut, and her daily task, though faithfully performed, tends to become one of mechanical routine.
One of the chief duties of the superintendent is to train new nurses, and she should renew the personnel of her staff whenever the welfare of the work demands a change. Sometimes, when a nurse shows flagging energy and interest, sufficient stimulus may be given by removing her to another district, where she will encounter new patients and new problems, and so regain her old keenness and ability. When one once becomes thoroughly tired of this work, however, it is unwise and futile to attempt to continue it. Therefore, in the interest both of the nurse and of her work, it does not seem wise to offer inducements for prolonged service, unless the individual characteristics of any given nurse make this wholly desirable.
Carfare. In addition to salary, a reasonable sum of money should be allowed for carfare. This allowance should vary in accordance with the territory to be covered, those nurses who visit in smaller areas naturally having a smaller allowance for the purpose. While economy in this matter is always necessary, it must be remembered that undue economy in carfare is wasteful of something still more important,—the nurse’s time and strength. If she is obliged to walk long distances between cases, this will greatly reduce the number of visits she can make in a day. Moreover, she will spend so much energy in mere walking that she will become too tired for effective teaching. Only fresh, energetic people can teach; those who are physically tired are apt unconsciously to let the obstinate patient have his own way.
Transportation. In small towns and country districts the problem of transportation is often a difficult one. There are either no street cars, or their service is very restricted and inadequate. Under such circumstances it will be necessary to provide the nurse with a horse and runabout, especially if she is expected to cover a large territory. Unless there is proper provision for transportation, it will be impossible for her to visit the patients often enough to make any impression,—her teaching will be laid on too thin to have much value. And to depend upon haphazard, volunteer offers of transportation is almost as bad as to expect her to make her rounds on foot. She should be given proper facilities for going from case to case, and should be able to plan a day’s work unhampered by any considerations as to if or how she can reach her patients.
Telephone. In making up the budget of necessary expenses, a reasonable sum should be set aside for telephone calls. The nurse has constant occasion to communicate with doctors, institutions, social workers, and so forth, and this item of expense should not come out of her own pocket. A careful weekly account of all expenditures, including telephone calls and carfare should be rendered by her.
Vacation. A vacation of at least one month should be given during the year. Less than a month is not sufficient time in which to recover the physical and nervous energy expended during the rest of the year. This holiday should be taken all at one time, rather than split up into shorter vacations, taken at intervals throughout the year. We all know that a week or two is not sufficient time in which to restore a thoroughly tired person; at the end of such a short period, one is just beginning to feel rested, and there has been no margin left over for amusement, which is a necessary part of all holidays.
Strong emphasis must be laid on the fact that if a nurse expects to return to her work and continue it successfully for another year, she should use this vacation as a means of fitting herself for another year’s close contact with an infectious disease. She should return to work thoroughly rested, with her resistance increased by rest and recreation, not lowered by injudicious use of this time off duty.
Sick-Leave. While a nurse is supposed to be sufficiently well and strong to go on duty every day, in all weathers and at all seasons of the year, a reasonable allowance for illness should nevertheless be made. Two weeks’ annual sick-leave is a good allowance. If a woman is off duty for longer time than that, needless to say her work must suffer and her patients must be neglected. If a nurse is constantly off duty for small ailments, this shows that she is not strong enough to undertake this arduous work. A fixed allowance for sick-leave, therefore, will tend to work automatically, and will eliminate the unfit, whose burden of work is otherwise added to that of the steady working members of the staff.
In the case of acute illness, such as typhoid fever or appendicitis, it would be perfectly possible to appoint a substitute until the nurse was able to resume her duties. If no time has been taken off for sick-leave during the year, the two weeks should be added to the time granted for vacation. If exceeded during the year, the salary for every day thus lost should be deducted from the monthly salary. This procedure may seem harsh, but with a large staff it is necessary. It places a double incentive on keeping well, and nurses who would otherwise have been thoughtless and careless as to their health, will take excellent care of themselves, in order not to lose one day of their coveted vacation.
In Baltimore, the municipality gives two weeks’ vacation, and two weeks’ sick-leave. If the sick-leave is unused, a reasonable vacation is the result.
Uniforms. The question as to whether or not a nurse shall wear a uniform is one which usually excites much discussion. The one or two disadvantages of such a dress are more than offset by the numerous reasons in its favour. Two objections are usually raised to wearing it: by the nurse, because it makes her conspicuous; and by the patient, because the uniform makes him a target for neighbourly gossip.
Let us consider the first objection, that made by the nurse. A nurse does not feel conspicuous when on duty in her district. Her busy, daily routine, taking her in and out of homes where she is needed, soon causes her to forget her personal appearance. A self-conscious woman is hardly the right sort for this work. The only rub comes when she is off duty and going to and from her district, but this cannot be held to constitute a serious objection.
As for the patient’s objection—he would be equally conspicuous if regularly visited by any woman unknown to the neighbourhood, no matter how attired. Prying eyes would recognize her as an alien, and the neighbours would speculate accordingly. We have often heard of patients who for fear of what the neighbours would say objected to being visited by agents of the Charity Organization Society. Yet the agents of that Organization wear no sort of uniform. The truth is, it is usually really the visit itself which is objected to, rather than the costume of the visitor—the costume merely serving as an excuse. On analysing the objections of a group of patients who disliked the uniform, they were found to be, without exception, patients who strongly resented every suggestion made to them. Their one desire was to be let alone, to be as careless as they chose.
On the other hand, the advantages of the uniform are many. In the first place, all effective care given to a consumptive has to include nursing as well as teaching. Now, one can “educate” in a woollen dress, but one certainly cannot give bed-baths in anything but a cotton dress, which can be plunged into a tub and washed. And whether she enters the home to give a bed-bath, or whether she goes in merely to distribute prophylactic supplies, the fact remains that a nurse spends some eight hours a day in contact with an infectious disease. Good technique demands that she be dressed in washable material.
In summer, a dress of washable material is not conspicuous. In winter, it may be covered with a long coat. And if we admit that such a dress is necessary, what objection can there be to making it of simple and uniform design? A single nurse so arrayed looks neat and business-like; a staff of nurses looks equally so. Moreover, uniformity of dress suggests uniformity of method, standard, and character of work, and hence inspires confidence. A staff of nurses, each one dressed according to the hazard of her own fancy, would hardly create the same impression.
In itself, the uniform is a protection to its wearer. It enables her to go freely and without molestation into all kinds of tenements and lodging houses, into side alleys and back streets. The well-known dress surrounds her with recognition, affection, and respect.
The uniform is also of value to the patients and to their friends. It enables them to recognize the nurse as she passes, and to call upon her as she goes by.
The uniform worn in Baltimore consists of a plain shirtwaist suit, worn with white linen collar and black necktie. The dress is made of blue denim, such as is used for overalls. Denim of this sort has two sides, a light and a dark; the dress is made up with the light side out, as in washing it seems to “do up” better than the darker side. Black sailor hats are worn, and in winter long, dark coats protect the dresses. This uniform is not necessarily the last word as to what a uniform should be, but it is simple and inexpensive, and the nurses look well in it.
Badges. The staff of a municipal nursing force is usually provided with badges to denote that they are connected with the Health Department. These badges should never be worn conspicuously, although they should be readily accessible. They are only occasionally needed, however, as when entering some lodging or rooming houses, or houses of prostitution, or other places where there may be marked opposition. To show them when entering a private home would be bad policy. A nurse usually enters a private house as a friend, but a public house she is sometimes obliged to enter in her official capacity. In dealing with all her patients, however, no matter where they are situated, the less show made of officialdom the better. By the time her patient finds out that she is connected with the Health Department, she should be already firmly established as his friend, and then the discovery will have no terrors. Indeed, at that stage, it very often enhances her value, and patients often feel intense pride at being visited by the “city nurse.”