Addenda as to Mixed Nursing by Nurses and Orderlies in Military Hospitals on the Double Pavilion Plan.
Orderlies’ Duties
I. After much anxious thought, re-consideration of all things, and pondering, I submit—
1. That three Orderlies will efficiently serve a ward of from 28 to 30 patients, including night-duty.
2. That each of two wards of 30 each, should there be two such under the same Head Nurse, on the same flat, ought to be entirely separate in all other respects.
3. That if night-duty be required, each such ward should have an Orderly on night-duty.
4. That each such ward should have a scullery.
With regard to these questions, I further submit—
1. Economy of hands, combined with efficiency of service, is an urgent thing in all Hospitals; most of all in Military Hospitals,
On the score of expense;
On that of efficiency of inspection;
From the nature of Military Hospitals, where the aim should be throughout to combine great simplicity with thorough efficiency;
From the importance of training the staff, male and female, of Military Hospitals, for service in War Hospitals, where every man or woman who can be spared is better away.
2. Yet economy of hands, carried too far, becomes, like all other such economies, penny wise and pound foolish.
3. Without doubt, large wards can be efficiently served by fewer hands than small or moderate wards. But, as sanitary considerations limit the size of wards to from 24 to 30 patients, let us make this the basis of all calculation.
4. The more it is considered, the more essential it appears, to train Nurses, from the first, to do efficiently a great deal of work. A small staff of respectable, laborious, and thoroughly efficient women seems the thing to be aimed at; whether considering Military Hospitals by themselves, or as a training-school for Hospital war-service.
5. It would be better to give each Nurse one great ward; but wards above a certain size are inadmissible for sanitary reasons.
6. The care of 24 to 30 patients is not sufficient duty, by a great deal, for a Nurse.
7. Therefore, upon the whole, and as decidedly the lesser of two evils, I recommend assigning to each Nurse two wards.
8. It is less difficult, and less objectionable, that she should have charge of two wards on one floor, than of two wards on two floors.
9. As regards the Nurse, I recommend therefore, upon the whole, to give each Nurse the charge of two wards of 30 men each; the wards to be on the same floor; but, except as being under the same Head Nurse, entirely separate.
10. It is important to repeat that the Nurse (who is Head Nurse), will be set free of two things, which consume much of a Civil Head Nurse’s time.
(1). “Settling the diets,” and fetching, besides waiting for, portions of those diets (e. g. wine) and medicine.
(2). Distribution of Diets.—It is quite possible that, in no long time, it may be found desirable to assign this duty to the Nurse. But it would be better to try to have it efficiently, which implies honestly, discharged by the Ward-Master. It will relieve the Nurse daily of considerable time; and it charges the Ward-Master with a definite duty which he can perform. The more he has defined duties, the less he will be inclined to fidget and disturb the Nurse. He is pretty certain to do this; but definite duties will diminish the tendency.
I should avoid giving the Ward-Masters too few wards. Otherwise they will make themselves insufferable obstructions, one way or another, to the Nurses. I should say that each Ward-Master, in charge of a Pavilion of six wards of 30 each, besides the small wards for one, would not have at all too much to do. Where there are no Nurses, the Ward-Master should have Assistant Ward-Masters in their place.
N.B. Wine might be treated as medicine, and, as such, delivered by the Nurse. Wine and medicine are usually, in the Civil Hospitals, given from the Apothecary’s shop at the same time. Or it might be considered desirable to leave this duty to the Ward-Master. In either case, it will never do to serve a bad case at once with all his wine, and either to let him stupify himself by swallowing it at once to make sure that he has it; or to set it by his bed-side for the flies to spoil it, or for a dishonest comrade, or here and there an Orderly, to drink it. The Nurse should receive, whether directly or from the Ward-Master, the wine of such patients, and should administer it in successive small fresh portions. The intelligent administration of wine ordered to bad cases is one of those momentous minutiæ by which, I do believe, and believe more and more, many lives are, by God’s blessing, annually saved in English Hospitals which would be lost elsewhere. Of course the only Regulation about wine should be to specify whether the Ward-Master or the Nurse should administer it.
11. Relieved of the loss of time incurred by fetching and waiting, and relieved at starting, at all events, and we will hope permanently, of the time consumed in distributing the diets, I certainly consider that a Nurse of the class of which, please God, Her Majesty’s must all be, (strong, laborious, active, and conscientious women,) can efficiently serve two wards of 30 men each.
Orderlies.
12. I should prefer wards of 30 each to wards of 25 each.
13. In forming rules for the proportion of Orderlies to sick, it is important to consider that the duty varies extremely according to the appurtenances of the ward.
14. I consider extreme plainness and simplicity to be proper and indispensable to a Military Hospital. Let us take for granted (and may it prove correct to do so), that in none of Her Majesty’s Hospitals Orderlies’ time will be wasted in cleaning any ornamental things, whether unnecessary furniture, flourishes, or cornices, &c., &c., on necessary furniture; supernumerary shelves, nooks and corners, &c., &c. Once provided, all these things must be carefully and constantly cleaned, or they become receptacles of dust and breeders of fleas; and to clean them involves enormous waste of time. A few minutes daily wasted on each of many things, make an enormous sum.
15. But it is very true economy to supply, if possible—which in old buildings it often is not—every ward of every hospital with a constant supply of water, (taking care that it is not wasted by mischievous or childish patients); and to give every ward of every Hospital the use, under proper control, of a lift by which, at fixed hours, food, medicine, linen and fuel are brought into the wards.
Believe that this is not theory, but the result of practical observation, much extended.
16. Now, these two things—supply of water (if hot and cold so much the better, and supply of water imports, of course, the appliance for getting rid of it, and of the contents of bed-pans, &c., &c., by one or more sinks) and the use of lifts can be applied to a new Hospital; can possibly, not certainly, be applied to some of the old Hospitals within the Kingdom,—can certainly not be applied to many of the Army Hospitals abroad.
17. Upon an average, these two things make the difference of one Orderly’s duty to a ward of 30 men.
18. And a ward of 30 men, so supplied, would be efficiently served by half a nurse and three Orderlies, including night-duty.
19. Without these two things (it is a mere comparative question as to loss of time and absence of thorough cleanliness, whether the water is brought from a pump in the court, or a stream some hundred yards off, above or below), and many, if not most, Army Hospitals abroad, must always remain without these two things, I consider that one Orderly to every seven patients will not be too much; while it is certain that, other things being equal, the ward with the appliances and the three Orderlies will be better served than the ward without the appliances and with the four Orderlies. Where there is no Nurse, one Orderly for 7 patients will always be advisable.
In these memoranda as to Orderlies’ work, &c., no notice whatever has been taken of the possible abolition of scrubbing, because it does not do to count unhatched chickens. If, however, that formidable weekly business could be got rid of, as well as the bi-weekly or daily washings of bed-head-floors, &c. the labour of the Orderlies would be, without underrating that required for keeping oiled floors cleaned, very materially lightened.
Night-duty of Orderlies.
20. Convalescent wards, which will be of great use in many ways, will be of use here. With them Nurses will have nothing to do. It is possible enough that, in course of time, the Medical Officers will desire to have Nurses there, and that it may be useful to place there elderly, still efficient Nurses; but let this come or not as it will, and let us keep quite clear of them, at all events, till the Nursing-service be tried and established in Army Hospitals. In these wards, night-duty will probably be quite unnecessary, though in that case either an Orderly or Assistant Ward-Master ought to sleep at hand; and night-duty is a service which must be spared wherever it can be spared, and rendered as efficient as possible wherever it is really wanted.
I have before submitted that in Paris, Vienna and Berlin, the average of severe cases in Army Hospitals, in time of peace, is very considerably lower than in Civil Hospitals.
This quite as much applies to English Army Hospitals. Whether the ordinary wards would require night-duty I do not know. If they often did, I should prefer having a regular night-duty in them. If they seldom required it, I would not have it.
21. In Civil Hospitals, served by women, I should undoubtedly prefer assigning the night-duty to one Assistant Nurse.
22. But Orderlies are in sundry respects different, and, upon the whole, I recommend not to have night Orderlies, but to let each Orderly in turn do the night-duty.
23. It is important to remember—the more so as it is often forgotten—that to lay more upon human nature than its Maker has made it to bear, is to do a foolish, let alone a wicked thing. Upon an average, all men and women can dispense with, or abridge sleep for more or less time. Upon an average, all men and women, after a laborious day, require a good night, in the long run. When they do not have it, either health, efficiency, or sobriety, or all go.
Believe, again, that this is not theory, but the result of practical observation, much extended.
A strong soldier is no exception to the general rule. In the long run, if made to do night-duty after a laborious day, he will either go to sleep, or drink to keep awake, or he will get knocked up before his time. And this it is part of his business to be in time of war; therefore, in peace-service, it is economical to let him last his time. It is then sound economy to give watchers sufficient sleep.
Scheme of Night-Service for Three Orderlies watching by turns.
24. Supposing regular night duty required, in a ward of 30 men, supplied as above, and served by half a Nurse and three Orderlies, it might be worked thus: the Principal Medical Officer would decide whether the same Orderly should do the night duty for a week, or the three on successive nights: probably the latter. The Orderly might come on night duty at 9 P.M., and remain on duty until 9 A.M., thus taking his share in the heavy morning work of cleaning the ward, &c. In all well-ordered Hospitals it is required that this should be done by 10 A.M., in some by 9 A.M. Earlier is undesirable in the English latitude (in other climates it is different), unless either the patients are to be disturbed earlier than English Surgeons consider right; or the ward, &c. cleaning is hurried through. A large ward, got into thorough order by 9 A.M., is in very good time. Of course it may happen occasionally to be got ready somewhat earlier, but this refers to the average.
Scheme for Three Orderlies A. B. C. Serving Ward X.
Monday, 3 P.M. A goes to bed, after taking his share of the morning work, eating his dinner, and helping to clear away ward dinner, &c. 9 P.M. A comes on night duty, after 5 hours’ sleep, and allowing 1 hour for undressing, dressing, and eating his supper.
Tuesday, 9 A.M. A goes off duty, having watched until 6 A.M., having breakfasted, having taken his share of the morning work, and leaving the ward clean. Let him have the option of one or two hours’ fresh air, either now, or before 3 P.M.; let him sleep full three hours; let him have his hot portion of dinner taken to him at the usual hour, unless all the Orderlies on night duty are served together at a different hour; and let him, 3 P.M., return on duty, washed and shaved. B goes to bed, &c.; 9 P.M. B comes on night duty.
Wednesday, 9 A.M. B goes off duty; 3 P.M., C goes to bed, &c.; 9 P.M., C comes on night duty, &c.
I have reckoned 12 hours for the Orderly to be off duty. It is better for him to have eight than seven hours’ sleep, and one or two hours’ fresh air are more healthy, and make a man last longer than going to and from his bed and his ward. An English soldier comes on duty clean, washed, and shaved, a once national peculiarity it is highly desirable he at all events should retain—at any rate that of thorough cleanliness—the shaving is unfortunately now not certain; for this and for his meals, some little time must be given. I think you will get more, and get it longer, out of the man by giving him 12 hours on night duty and 12 hours off. Still it will not do to interfere too much with analogies, and the proper authorities must decide whether this is too much.
Exercise for Orderlies.
25. Again, leaving the question for decision to the proper authorities, I had rather each Orderly had one hour or two hours for exercise each afternoon or each alternate afternoon, care of course being taken that he did not exercise himself in some tap. He should report himself to the Nurse, or to the Ward-Master, or Assistant Ward-Master on going and on his return. So should the Night-Orderly when coming on and going off duty. Also in many emergencies of no very unfrequent occurrence at home, and constantly abroad, the Orderly must dispense with recreation time. But as a rule, it is certain that fresh air is necessary to preserve health in Hospital duty. Doctors of all kinds know and act on this as regards themselves.
The waste of time and strength, at present too often incurred by the endless fetching, heavy carrying, &c., of many Hospitals is in a considerable degree counteracted by its forcing the Nurses into other than ward air; the air of a Hospital Court is better than that of the best ventilated wards as it is, not as it might be. The same applies, in its degree, to Orderlies. But it is better, and far more economical, to avoid the fetching and carrying as much as possible; to keep the ward attendants in the ward to their duty under the supervision of the chief and responsible ward-servant; and to give each in turn a short daily recreation, if possible.
Night Refreshment for Orderlies necessary.
26. Now comes a thing I am very anxious about concerning night duty, the more anxious because it is important, and because I am afraid it is an innovation. I have watched the night duty with particularly anxious interest, in each Hospital I have entered, feeling at once its importance and its difficulties, and of the following principle I am thoroughly certain.
The Orderly doing night duty should either be allowed refreshment during the night, or the recurrence of this night refreshment should be considered in allotting the rations.
In none of the Civil Hospitals, so far as I know, is night refreshment given. The Nurses usually on board wages, apportion, when they can, some from their food. In one Hospital there exists a rule that no Night Nurse is to take refreshment during her watch, the intention being to keep her more vigilantly to her duty. This is one instance among many of the serious and cruel mistakes which men of business or benevolence, or both, make, when legislating on matters which they do not understand. It is, fortunately for the fine Hospital where it is the rule, practically disregarded; the Head Nurses knowing well that a Nurse watching and fasting in a ward from 9 to 9, or even from 9 till the breakfast hour of 6, would either soon be unfit for duty, or put drams in her pocket, or doze through the night.
A strong soldier, required to watch in a ward and fast from 9 P.M. till 9 A.M., or 6 A.M., or shortly before, would stand the trial quite as ill as a Nurse. There is an admirable rule at two foreign Hospitals where I have served. Sisters watch in some wards, Men Nurses in others; and each watcher receives from the house, on going on night duty, a bottle of beer, a can with about six or eight cups of coffee, milk and sugar in proportion, and three slices of bread and butter. The Sister’s bottle of beer is about one pint; the Man-Nurse’s double; his coffee can is also a good deal larger. The rule of allowing sufficient for three solid refreshments (which of course can if desired be made by the watcher two or three) during the night, is an excellent one.
I think it would be very sound economy to allow each Orderly on night duty, a proportion of beer or porter, of coffee or tea, and of bread and butter, or bread and cheese, to take at his own time during his watch, besides his supper before going on duty, and his breakfast just before 6, (both Nurse and Orderlies ought to have breakfasted by 6, and to begin the day duty at 6, and I wish it began by opening the windows and repeating the short prayers for 5 or 6 reverent minutes). Of course it may be considered preferable to reckon this night-ration in the Orderly’s rations. Or suppose the bread and beer or porter to be reckoned in the rations, and a can of coffee given him for the night watch. Settle details as is best, and of course analogies must be considered; but in truth hospital watching is a very peculiar business; important, unobtrusive, most peculiarly trying, and the bright side of very few Hospitals. Each watcher should undoubtedly have refreshment for the night.
The Nurse should have her groceries in the lump, and refresh herself as she likes out of them. Her watching, if she does her duty, will be, when she has bad cases, severe enough; but I would not provide her with extra refreshment; as the watching is not prescribed and regular duty.
There should be as little extra watching on the part of Orderlies as is possible; when it is indispensable the extra watcher should have the same night-ration. I submit my strong impressions on the subject of this night refreshment now, because, small as it may seem, it very largely enters into the working of a night watch.
I have suggested the division of the Night Orderly’s sleep, because, if A. comes on duty at 6 A.M., and is sent to bed at noon or 1 to get ready for his night watch at 9 P.M., he is scarcely fit for a long sleep, and supposing the patients dine at noon (an excellent hour) he has not, or scarcely, taken his share of the clearing away which, got over in time, enables the other Orderlies, one or both, to have a short recreation in the afternoon. Also if sent to bed at one he has not eight hours’ sleep, as out of that he has to undress, dress, and sup. Also he has to remain on duty from 9 P.M. to 9 P.M. next night, which is much too long as a rule. If he does not go to bed before his watch, and goes off duty at 9 A.M. next morning, whatever time may be then allowed him for sleep, he cannot, as a rule, be depended upon for performing his watch duty efficiently.
Where are the Night Orderlies to Sleep by Day?
27. If the Ward Orderlies watch by turns, it should be arranged that the men who sleep before and after the watch can do so quietly. This is by no means always attended to, as to Nurses in Civil Hospitals. Upon the whole, I cannot think it would answer to have always the same watchers, as regards Orderlies. The other Orderlies, supposing them lodged apart from the wards, will certainly go seldom enough to their quarters during day, except during their exercise time. It may be thought essential to retain soldiers under very primitive notions as to quarters. So though in a dormitory of women, I think little cells, parted either with a partition or a curtain, the whole thoroughly airy, are in all respects preferable to unparted rooms, it may be, by some, thought better that the Orderlies shall sleep in large airy wards, not parted by curtains or partitions. I know, however, one high Military authority, at least; who considers the same reasons apply to men as to women in this. Soldiers are generally able to go to sleep whenever ordered. Indeed their general capacity of doing whatever they are bid is one of their many fine points. The Orderlies’ wards must be under some sort of inspection, and noise must not be suffered in them. Non-Commissioned Officers, either Ward or Assistant Ward-Masters, or some special functionary (but such I would not multiply) must sleep near, and have general charge of the order and quiet of such wards. I conclude that one or more Assistant Ward-Masters, at all events, must watch, and as they must sleep by day, this will fit in well enough.
I should avoid putting the Orderlies in a too much out of the way part of the Hospital; they should know themselves liable to inspecting visits any time. I am not sure that Ward or Assistant Ward-Masters would not be much better guardians of the Orderlies’ wards than any special functionary. Drink is the vice of these men, noble fellows as, as a body, they are, and I should avoid quartering any man too comfortably and solely in one particular post. Cases have been where the duenna of the Nurses’ dormitory was herself a determined, disguised drunkard, and reported others accordingly as she was bribed or not with drink for herself.
The whole question of Orderlies sleeping near or away from their wards should be well considered by the proper authority, two or three experienced Army-Surgeons. Upon the whole, I think it would be well to try the quartering them separately: there is much to be said on both sides as usual.
Comparative Merits of Different Systems of Night Nursing.
28. In several foreign Hospitals a certain number of Night Watchers, both Sisters, and Men-Nurses, are told off for night-duty for four weeks, during which they are exempted from all labour by day, and receive better food than the usual diet. They also receive good night-refreshment.
In one Hospital the following is the arrangement. The wards usually contain from 10 to 13 beds, and there are many small wards for three, two, or one, bad cases or operation cases. All the wards open upon a corridor. The Sisters do not watch in the men’s wards.
| A Sister watches in the female medical wards | 5 Watchers | |
| A Sister watches in the female surgical wards | ||
| A Sister watches in the children’s wards and girls’ ward | ||
| A Man-Nurse watches in the male medical wards | ||
| A Man-Nurse watches in the male surgical wards and boys’ ward |
An operation-case, or an extra bad or anxious case, or a case requiring special attendance and put in a single ward, has an Extra-Watcher. Often there are no Extra-Watchers: sometimes there are several at once. The Extra-Watcher is either a Sister or a Man-Nurse, taken from among the other Sisters or Men-Nurses, who, after his or her day’s duty, does the extra watch.
As regards all English hospitals, civil or military, the advantages of this system are these:—
1. It severs certain persons for night-duty, who have full time for sleep and refreshment in the air during day, and who are allowed to do no other work.
2. It secures these persons good food and refreshment at night.
3. These persons know their sick, and, being told on coming on duty, of any change, &c., are as much at home in their posts by night as others are by day.
4. When it is found that a Sister cannot sleep by day, and, therefore, that her health breaks, she is not allowed to finish the four weeks and become ill, but is put to another duty and another Sister appointed to the watch.
(Many a strong Nurse cannot sleep at day.)
5. The persons so appointed get into the way of it, if they stand it at all, and the system is found a great relief to the whole house and a great gain to the sick, in the place of another system of dividing the night between two Sisters and two Men-Nurses, who each watch half of the watch.
Per contrà.
I. The great London hospitals are places very far from perfect: some things may, please God, be, with time, patience, and extreme quietness, very much improved; but some things will never be perfect and never can be. But they are places where I do believe, and so far as I know, the sick are cared for in a way that is done nowhere else. The proportion of heavy cases in every London ward, cannot, I think, be met except by having a watcher in each. An English physician or surgeon would not consider that his cases could otherwise receive the attendance and the watching, the observation of possible change and prevention of possible mischief, which they ought to receive.
It is right to bear in mind,—
1. That small wards multiply exceedingly the demand for Watchers: four wards, of 10 patients each, taking the average of patients as in London, would not be attended, according to the English notion, by one Watcher; 40 patients in one ward would be fully attended by one Watcher. The London Hospital has two Night-Nurses for its quadruple wards. An extra Night-Nurse has frequently to be put on, on account of the difficulty the subdivision of the ward gives to the watching.
2. That the average of severe cases in each ward of London hospitals is very considerably more than the proportionate average of severe cases in each ward of the foreign hospitals in question. In all foreign hospitals with which I am acquainted the proportion of accidents is comparatively small to those of the London hospitals. The docks, the manufactures, the crowded and dangerous works, &c., &c., with us, account for this.
3. That, striking the balance for and against, it is necessary that each London ward should be watched by a Nurse; at the same time, that without doubt a certain number of troublesome, ill-conditioned patients (no ward of any Hospital is without such) sleep soundly and let their neighbours sleep soundly when the Watcher only looks into the ward at frequent intervals, who would, if the Watcher sate in the ward the whole night, make it their business to require attendance from the Watcher during the whole night, or at least much oftener than by the other plan.
II. The second flaw of the above system, as it applies to London Hospitals, is, that it renders Extra-Watchers so often indispensable.
The employment of Extra Watchers can never be wholly prevented, but it should be the endeavour of every Hospital to employ such as seldom as can possibly be. Extra watching is most injurious to the health of all ward-servants, and to the sobriety, and therefore morality, of many paid ward servants.
This is a very important reason, I humbly consider, for avoiding as much as possible small wards.
I do consider small wards very objectionable in working a Hospital.
But it is right to remember that we have been told of England, of Austria and of Prussia that the proportion of severe cases in Military Hospitals in time of peace is considerably smaller than in Civil Hospitals. Night watching is not done in the Military Hospitals either of Vienna or Berlin. Orderlies, or an Orderly, sleep in each ward, and watching is only done to bad cases.
How far English Army Surgeons consider night watching desirable in the Army Hospitals I will presently tell.
I should think the convalescent wards, among many important advantages, would receive a number of patients who require no night watching. An Orderly ought to be at hand here, but not watching.
If night duty is considered requisite in the ordinary wards, I do not see how the English standard of things could be met, excepting by having one Watcher in each ward where there is regular night watching.
I think, however, that the foreign system of night watching above detailed might give very useful hints for women in war service, and for emergencies of cholera, &c., &c., in home service; and with regard to supervision in the latter.
I think, with submission to the proper authorities (the two or three experienced Army Surgeons I have so often adverted to) feeling strongly that awkward mistakes might occur in several of these matters without them, as civilians and women cannot and ought not to trust their own judgments respecting such, that in a large Military Hospital, an Assistant Ward-Master ought to go round the wards at night. Not with any idea of his rendering assistance to the Watchers over bad cases. The Nurses must do their duty of Head-Nurses, and see to this themselves. Perambulation through a large Hospital at night in point of fact excludes the possibility of doing anything in any one ward, unless in some exceptional occurrence which only proves the rule. The object is the important one of seeing that the Orderlies are awake, sober, alert, and at their duty, and that the patients are quiet and in bed. The Nurse would hear any noise, but there is such a thing as quiet drinking, as well as noisy drinking.
In St. George’s there is a Night-Matron, chief over the Night-Nurses, who goes through the Hospital every hour during the night-watch.
I have heard this spoken of by experienced Authorities of other Hospitals with approbation and envy, and some idea was entertained of introducing it into another great Hospital. In Civil Hospitals, I think, but I do not know, that the benefits of this Night-Matron may be perhaps more imaginary than real. The Head-Nurses at St. George’s sleep away from their wards; a great mistake, I humbly consider.
But Military Hospitals are entirely different in sundry essential respects. I think a non-commissioned officer, Assistant Ward-Master for instance, ought to make his rounds every night. When once such a service takes place, every hour is better than three or four times a night. He must be “up to” sundry things—taking the wards in uncertain rotation, sometimes returning suddenly on his steps, &c., &c., &c.
It will be worth securing, if possible (this parenthesis will be understood), that the Nurse’s water-closet should be within her room, if not, as close to it as may be.
Present State of Night-Nursing in Military Hospitals.
29. The following extraordinary system of Night Nursing is that which prevails in the Army at present:
The “nursing is managed” either by means of patients “told off in watches” through the night for the purpose of attending to other patients, or by means of soldiers sent in from the ranks to attend specially upon each bad case; or by Orderlies “arranging it among themselves,” without any exemption meanwhile from day duty.
Upon each and all of these systems or no-systems it is hardly necessary to make any comment. It is difficult to tell which is the worst.
In the principal, indeed the only General Hospital in England, “Nursing is managed by comrade-patients told off in three watches of two hours each for the night.” [sic.]
“Orderlies are likewise warned and often sit up for the purpose.”
These passages are given verbatim et literatim, because they are so remarkable.
And it is necessary to add that these patients being the relapses among the “Invalids” are nearly the worst cases we have.
Were it the report of a Head-Nurse in a Civil Hospital to her Resident Medical Officer, it would undoubtedly cost her her place. One scarcely knows whether to pity more the sick patient or the orderly patient. One scarcely knows how to estimate the amount of medical comforts intended to be consumed by the sick patient which will actually be consumed by the sitting-up patient, and necessarily so. And the expedient which turns over the man who is too ill to be left at all to the care of men who ought to be recovering themselves, but who are pulled out of their beds for two hours to nurse (for the first time perhaps in their lives,) and a very “serious” case too, is to say the least of it a singular one.
At Woolwich Artillery Hospital the cases which require constant attention are about 2 per cent. There are now 545 patients in Hospital, and 11 cases consequently, each requiring one Orderly to itself. The Orderlies, according to Regulation, are 55, so that one-fifth part of the Orderly service is required for these cases. Yet there is no system or arrangement for such. The Orderlies arrange (or do not arrange) among themselves to do the reliefs day and night. Of the 11 cases at this time in Woolwich Hospital with 11 Orderlies sitting up with them, it so happens, as I am informed, that only one would require, if such were together in wards where regular night nursing was established, an attendant specially to itself.
It is needless to enlarge upon the cruelty of the above practice. The one serious case is disturbed in the day by the goings to and fro, the noise and bustle of the light cases—while these are disturbed at night by the sitting-up necessary for the one bad case, which may be besides, and too often is, a noisy or offensive one. The bad economy is as obvious. It often happens that 11 cases who might all, if in one ward, be attended and as efficiently attended, by one Night Orderly, require each an Orderly to itself in as many different wards.
In the “Garrison Hospital” at Chatham, “when any case assumes such a character as to require more than the usual care and watching, a Requisition is immediately sent to the Commanding Officer of the Corps to which the man belongs for a steady well-conducted soldier and who generally is the man’s own comrade” [so much the worse] “to nurse him, and to attend upon him throughout his illness, but who is relieved by another as often as the Medical Officer in charge of the case considers necessary.”
The following is the average number of sick in Army General Hospitals in time of peace at home, for whom night-nursing is considered necessary by the Medical Officers. But it is important to add that this number would be probably estimated as very much higher if proper means of night-nursing were at their disposal.
Of constantly sick mean proportion per cent. requiring night nursing:
| General Hospital, Fort Pitt Medical Division | 5 |
| General Hospital, Fort Pitt Surgical Division | 1 |
| Garrison Hospital | 2 |
These cases are usually scattered through the wards.
It is but fair to add that the best Medical Officers themselves desire another system, or rather are aware that there is at present no system at all, and would gladly accept one. “With means for good night-nursing,” they say, “arrangements in accordance might be introduced. At present we like to have a case requiring much attendance amongst cases that require little, in order that the patients or comrades may assist.”
What are the consequences of such “assistance” to the cases in question has already been fully stated throughout these notes.
Poor-Law Regulation for Nursing in Union Workhouses.
“With respect to the use of [the inmates as] servants, they require the strictest superintendence on the part of the * * officers. The employment of [the inmates] in offices of trust is inexpedient, inasmuch as it tends to impair the discipline of the house. In offices of mere labour, which can be performed under trustworthy superintendence, [the inmates] may be useful. Where responsibility is involved, paid servants should be engaged.”
The above is one of the regulations of what?—not of a Charitable Institution but of the Poor Law; and the house of which it treats so tenderly and wisely is—a Workhouse![19] If paupers are to be thus cared for, how should it be with our soldiers? If any “office” can be called one “of trust,” surely it is that of carrying out the orders of the Medical man in a critical case, a case of life or death! Can any “responsibility” be “involved,” greater than this? Yet these are just the cases left to the “Comrade Patients.” For ordinary cases the ordinary attendance is given; for serious cases, the untrained and unskilled attendance. Yet, if the Hospitals are not for these serious cases, what are they for? For these alone, however, is no systematic provision made. One would think that every bad case took the Hospital by surprise. Imagine the orders of the Medical Officers carried out by nurses (?) changed “every two hours,” and who are, in fact, sleepy patients!
The system of Military nursing and management, as described by Army Medical Officers themselves in the above quotations, and which is, we are expressly told, to be re-enacted at the Royal Victoria Netley Hospital, is precisely the one which led, as a matter of course, to the calamities, as far as nursing was concerned, in the Hospitals in the East, and which will lead to them again so long as it is continued. Even in the case of invalids, who may not require such careful attendance as sick, the system of nursing by comrades is most objectionable; and if the attendance at Netley can only be carried out on such a plan, it is doubtful whether Netley should be used even for an Invalid Hospital.
The question has been asked the Netley Committee, By whom are your Invalids to be nursed, when sick? And it has been answered, that they are to nurse each other!
II. Nurse’s Room, &c.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
III. Regulations.
Query as to depriving certain Patients of Visitors.
1. Proper military and medical advice should be taken as to whether it would be advisable to draw a distinction between the venereal and the other patients.
In the Vienna Military Hospital they are locked up by themselves in particular wards, but are allowed to see their comrades at visiting hours.
In the Berlin Military Hospital they are locked up in wards, and allowed to receive no visits whatever, excepting, of course, from the Chaplain and the proper Military and Medical Officers; and in the case of dying patients from their nearest friends.
Nor are they allowed exercise in the grounds.
This excellent regulation makes them heartily tired of the venereal wards, and even this is a very salutary thing.
In the Vienna and Berlin Civil Hospitals, the venereal patients of both sexes are also placed in locked wards, and allowed no visitors. Nor are they allowed exercise in the grounds or garden.
In the two Paris Venereal Hospitals no visitors are allowed.
Now, as the more disagreeable the subject, the more necessary it is to be explicit upon it when entered upon, this wholesome discipline exists in a very faint degree in our great Civil Hospitals,—a thing not to be lost sight of in introducing any change in the Army Hospitals.
The three greatest London Hospitals have venereal wards. The female patients never leave the ward. The male patients take exercise in the court. In one case the rule is, that this should be at different hours from the other patients; the rule is not strictly adhered to.
The exercise question should, in Military Hospitals, be left entirely to the Surgeons; they may fairly consider it enters into the question of treatment, which is different from the Continental treatment. The enforcement of different hours of exercise from those of the other patients is good, as is every brand which can, quietly and effectually, affix disgrace to these wards.
Deprivation of visitors, if it could be done, would be very salutary. In the great London Civil Hospitals, men and women visit the male venereal wards; women alone the female wards (and melancholy things are the visiting hours there; here and there a heart-broken mother, abundance of prostitutes, and no lack of procuresses. A firm and vigilant Head Nurse will sometimes refuse admitting one of the two latter sorts to some patient, whom she knows they are endeavouring to make sure of again; but as the rules admit female visitors, and she is by rights only entitled to eject a visitor whose behaviour is disorderly in the ward, the Head Nurse can only do this in point of fact by straining the rules, and cannot do it often). The female visitors of the male venereal wards are usually, on the average, much less disreputable than those to the equivalent female wards; and are generally wives, mothers, and sisters, seldom prostitutes. There can be no doubt, however, that it would be much better if the patients of neither male nor female foul wards were allowed visitors, unless in the comparatively very rare cases of extreme danger; it would, in that case, be necessary that the Hospital should supply them with linen, and either supply them with groceries or forbid their receiving them from without.
In various essential respects the patients of a Military Hospital are different from those of a Civil Hospital. Were it possible to prevent all female visitors to the wards, except in dangerous cases, this would be best. If the existing rules or practice do not compel the sentries to refuse entrance to all disorderly women, however orderly their behaviour, such a rule, at any rate, should be enforced. And if all visitors, male and female, including, of course, soldiers, could be refused admittance to the venereal wards, always excepting cases of great danger, it would be very desirable. At all events, it would be very desirable to have all female visitors, without exception, excluded from these wards. These things are, I do consider, very important. But I would not press them, if refused.
Let the female service obtain, please God (I do not write these words pro formâ,—if possible, I feel every day more intensely how solely it is to Him we must trust in this difficult work,—the more so that, if possible, I feel every day more intensely the importance of, if He grants it success, improving secular Hospital nursing, leaving the English Sisterhoods, which will always have great advantages, and, I believe, great disadvantages, with reference to Hospital nursing, to take their share in this great field, which has plenty of room for both), let, I say, the female service obtain a firm footing in the Army Hospitals, and with it, and by cautious degrees, sundry ameliorations will creep in insensibly as to decorum among other things. Those solemn beautiful words I have always felt so full of meaning to us, “In quietness and in confidence shall be your strength.”
Query as to Numbering Patients.
2. Military as well as Medical advice should also be taken upon the following point:
In most, not all, the great London Hospitals the patients, whose names are on their bed-tickets, are called by the numbers 1, 2, 3, &c., suspended over each bed; sometimes a patient’s name is never heard in the ward.
Now, very possibly, this would not at all do in a Military Hospital, and, if so, there is not another word to be said about it.
Otherwise, very few things so effectually save time, as the numbering plan. (In Civil Hospitals it is also excellent in other ways, of much less consequence in a Military Hospital, which will never, I conclude, be afflicted with “gentlemen,” Mr. So-and-So, and Master So-and-So, which latter inscription is frequently to be read on the letters of little boys in Hospitals, whose friends, on visiting days, also enquire for them by that title). But few things, I repeat, so effectually save time as numbering instead of naming the patients (names, of course, to be on bed-tickets). If, however, the officers consider it “unsoldierly,” give it up at once.
Regulations as to Swearing.
3. The regulations lately in force contained in plain strong language prohibition of swearing and indecent language in Hospitals; they are quoted from the Articles of War. It would be well to retain this in any new Regulations; and the retention of this Rule is not the less important when women are put in charge of Military wards, since, though it is not their business to maintain discipline, it is their duty to call in those whose duty it is when discipline is infringed. And it is important that this prohibition of swearing and foul language should not be looked upon as an individual or collective crotchet, or female innovation, but remain the rule of the Service. Such language would never be used in the Nurse’s presence unless by her own fault. But it should be unheard in the ward, whether she is in it or not. The old definite words should be transcribed.
Conclusion.
I do not like writing any part of the above, not because it can, in any sense, be said to strain the necessary principle of reserve, save for strictly business purposes, as to all which is, strictly speaking, Hospital business, but because of the extreme caution necessary as to this sort of topics. Still life is so uncertain that the possible introduction of permanent Female Service into Army Hospitals has determined me on writing what I had rather not have written.