Extract from a letter from the Right Honourable Sir John McNeill, G.C.B., dated Granton House, Edinburgh, 28th Feb., 1864.

There can be no doubt, I think, that it would be a mistake to have pauper nurses mixed up with paid nurses, and I think I expressed that opinion when we conversed about those things. Paupers might, however, be employed to scrub and to do other menial work, under the orders of the paid nurses. If the paid nurses are to do much good they must have a recognised authority in their wards. Without authority there cannot be due responsibility, and things must get into confusion. A nurse carrying out the instructions of the medical officer must have authority to do so, and resistance to that authority must be treated as a breach of discipline.

To put this upon a right footing from the first, would be indispensable to success. The more a nurse does by influence, and kindly influence, the better; but dealing with the promiscuous inmates of a workhouse, the knowledge that there is authority in reserve to be exercised if necessary, prevents the necessity of resorting to it, and makes the patients duly appreciate the kindness which keeps it in reserve.

With regard to all such matters, a great deal will depend upon the good-will, the good sense, and good feeling of the Governor and Matron, but especially of the Governor. He can do much to promote or to mar the success of the experiment, and so can the medical men; but if they be men of sense and right feeling, they cannot fail to perceive how vast an addition to their own comfort the permanent establishment of such a system as you propose to introduce experimentally, must produce.

The position of a medical man dependent for the execution of his instructions upon nurses who are neither intelligent nor trustworthy, is very painful, and tends to deteriorate his own character, both as a man and as a practitioner, by rendering him callous to preventible suffering which he is denied the proper means of relieving, and by compelling him to forego the use of remedies which require intelligence and conscientious care in administering them. The house Governor, if he be a conscientious man, must be kept in continual anxiety about the conduct of ignorant, and often worthless pauper nurses in the hospital, and is driven at length to be satisfied with a low moral and intellectual standard in the nurses, and a corresponding standard of care and comfort in the hospital.

The Select Vestry took the subject into their serious consideration, and instituted most careful inquiries in various quarters. Among other steps, they called for a report on the probable operation of the proposed system from Mr. Carr, the Governor of the Workhouse. That report ran as follows:—

Extract from the Journal of the Governor of the Workhouse.

Liverpool, Thursday, April 14, 1864.

In compliance with the instructions of the Workhouse Committee, I have carefully considered the proposal made to the Committee by a Liverpool gentleman, on the subject of nursing the sick in the Workhouse Hospital, and beg in reference thereto to report—

That, practically, the proposal amounts to this—that there shall not be any pauper nurses in the hospital, but that there shall be appointed in lieu a staff of duly qualified paid nurses and servants, with a head superintendent, under whom the whole of the nursing of the sick shall be conducted on the best known principles.

This proposal rests its claim to favourable consideration on the presumption that the present system of nursing the sick in the Workhouse Hospital is defective. The Committee are aware what that system is. It may thus be briefly stated. Certain wards of the workhouse are set apart as hospital wards. They do not form an hospital worked as a whole, but are divided into five portions, each forming a distinct set of wards, in close proximity to the wards of the healthy paupers, and in five different parts of the workhouse. These five sets of wards I shall call the Workhouse Hospital. The hospital is divided into eleven sections. At the head of each section there is an intelligent paid superintendent nurse, and under each such superintendent nurse there is placed a staff of pauper nurses, with the aid of whom she is required to work her division, according to certain rules and regulations made and provided for that purpose. A copy of these rules is appended hereto; from which it will be seen that the burden of the responsibility of carrying out the orders of the medical officers, devolves upon the head nurses or superintendents of divisions. The pauper nurses clean up the wards, carry the food, and give general assistance to the superintendent—the duties of nursing in detail, that is to say, the bedside nursing, falling chiefly upon them. They are not permitted, however, to serve any patient with stimulants, beer, porter, or medicines requiring exactness or care; all such duties are discharged by the superintendent nurse. The proposal now made to the Committee, means that the paid staff shall be increased, so that the sick shall be cared for by responsible officers only, and not left, even partially, to the care of pauper nurses.

There is no doubt that pauper nurses are unreliable, inefficient, and many of them very worthless; and it is only by careful watching, and the utmost stringency of regulations, that they can be made serviceable in the hospital. No stringency of regulations, however, could guard against the most flagrant abuses, if these women were employed to discharge duties of trust, such as serving out the stimulants, &c. so that their services in attending upon the sick are limited and common-place. There is therefore, in my mind, no doubt, and I cannot see how any doubt can exist, that to remove these women, and appoint in their places women of character, trained as nurses, will tend to improve the position of the sick, and more rapidly restore many of them to health.

To displace these pauper women, however, involves a complete change in all the hospital arrangements, and suggests the difficulty of finding and keeping up a supply of suitable nurses to undertake the work at, as it would no doubt often happen, short notice. The Committee are aware, too, that owing to the fact that the paupers have hitherto been required to attend upon the sick, the accommodation for paid officers is very limited, and that the adoption of the proposal would render it necessary at once to provide additional rooms for the additional staff. The Committee are also aware that the Workhouse Hospital differs from other hospitals in this—that it forms a part only of a mixed establishment, and that there are great difficulties to be overcome in completely cutting off every connexion or species of intercourse between the hospital departments and the healthy inmates, without which the scheme under consideration could hardly succeed. If any good is to result from the adoption of this proposal, the sick should be placed absolutely and entirely in the hands of a paid staff, without the assistance, in any form, of any one of the pauper inmates. Cut off the hospital department from the healthy wards; and do not, under any pretext, suffer communication between the sick and the healthy, and you strike at the root of every species of workhouse abuse; but if, under any pretext, you suffer a large number of healthy paupers to pass daily into the sick departments, as they now do, the adoption of the proposal will effect little good.

But the question has to be still further investigated on the ground of expense; and it has to be decided the number, pay, allowances, and accommodation of the necessary staff to work it out. Now, although I entertain very strong opinions as to the undesirability of employing paupers to discharge responsible duties of any kind, because to do so destroys the value of the workhouse test, and tends to reconcile them to pauperism; and although I view the particular work of nurse-tending as the very worst kind of work for paupers, inasmuch as, while so employed, they are better fed, have more freedom of action than they otherwise would, and can make their places emolumental—thereby holding out a positive inducement to pauperism; and although I have no doubt that the displacement of these women would be followed by the immediate application for discharges by a large per-centage of them; and although, at this moment, many other weighty considerations press upon me in favour of the immediate adoption of the proposal under consideration, I feel unwilling, in view of the difficulties to be overcome, some of which I have indicated, to incur the weighty responsibility of recommending such a course on my own unaided judgment. I have abstained, therefore, from taking up the question of expense, &c. but take the liberty respectfully to suggest, that a sub-committee be appointed to report upon the whole question in all its details. It shall be my anxious desire and pleasure to assist the labours of such sub-committee by every means in my power.

According to the recommendation of Mr. Carr, a Sub-Committee was appointed, consisting of men of great experience in parochial business, who went up to London, and had interviews with the medical and other officers of the two metropolitan hospitals where nursing has been brought to the greatest perfection—St. Thomas’s and King’s College Hospitals. Finding that some of these gentlemen wished for more information respecting the Workhouse Hospital system before they would venture to express decided opinions as to the economical results of the proposed reform, the Liverpool Visitors drew up a statement on several points affecting this question, with written inquiries, to which answers were returned, verbally or in writing, by the gentlemen consulted. This statement, with the replies which it elicited, is here given at length:—[2]

STATEMENT AND QUESTIONS OF THE LIVERPOOL SUB-COMMITTEE.

The population of the Parish of Liverpool is about 270,000.

The expenditure from the poor’s-rate in and about the relief of the poor is about 100,000l. per annum.

Of this about 40,000l. is distributed in out-door relief as money and bread. (Of course sickness is one great cause of persons seeking relief, though to what extent this cause operates, even directly, I cannot on so short a notice ascertain or even estimate.)

The expenses (direct) of treating the out-door sick are:—

Salaries of Medical Officers, &c. £1,800
Medicines, &c. 1,378
£3,178

The cost of maintaining the Workhouse Hospital may be estimated as follows:—

Maintenance of Patients £9,700
Salaries of Medical Officers 485
Medicines, &c. 1,050
£11,235

The Hospital contains accommodation for over 1,000 patients, and has often 1,000 in it. The cases at present are:—

Medical 485
Surgical 345
Fever 120
Smallpox 20

The weekly discharges are from twenty to thirty per cent. of the whole number in the hospital.[3]

The present workhouse staff consists of fourteen paid officers (who are superintendents, but not trained nurses), and about 150 paupers acting as nurses, but not paid. It has been proposed to add a trained hospital matron and trained nurses, such as those trained in the Nightingale School, and assistant nurses, so as to give one trained day-nurse and one paid assistant to about every three pauper nurses, and a trained night-nurse on every flat; it is further proposed to pay the paupers who act as nurses, wages. The cost of this would be about 2,000l. per annum.

Does your experience of hospitals lead you to believe that the cost of this improved system would be “in part,” “wholly,” or “more than” repaid to the ratepayers by curing people more quickly, by curing those who otherwise might have become chronic cases, and by enabling those to resume their work who must otherwise have remained or died, and by thus diminishing the duration or amount of that part of pauperism which is the result of sickness?

Salaries of Medical Officers, &c. £1,800
Medicines, &c. 1,378
£3,178
Maintenance of Patients £9,700
Salaries of Medical Officers 485
Medicines, &c. 1,050
£11,235
Medical 485
Surgical 345
Fever 120
Smallpox 20