Workhouse Nursing: The story of a successful experiment

by Florence Nightingale; William Rathbone

“I believe it would be quite repaid.”

REPLIES FROM THE PHYSICIANS, &c. OF KING’S COLLEGE HOSPITAL.

1. Reply of Henry Smith, Esq. Assistant Surgeon.

“I believe, from a long experience of hospitals and other institutions, that the cost of an improved system of nursing as proposed for the Liverpool Workhouse Hospital would certainly be ‘in part’ repaid by restoring the patients to health more quickly.”

2. Copy of a Letter from Miss Jones, Lady Superintendent of St. John’s House Nursing Schools, and Matron of King’s College Hospital.

King’s College Hospital, May 4, 1864.

Dear Sir,

The inclosed paper was sent to me yesterday, with the request that I would obtain from some of the medical staff of this Hospital answers to the question proposed at the end of the paper, in order to enable the Vestry in some degree to judge whether that body would be justified, or otherwise, in sanctioning the introduction to their Workhouse Hospital of an improved system of nursing the sick, at the probable annual money cost named in the inclosed paper.

I have accordingly submitted the paper to as many of the medical staff as I could see in the short time.

I inclose a note from Mr. Henry Smith, one of the surgeons, who has had considerable experience as to the loss and gain of good and bad nursing.

Dr. Wm. O. Priestly, the Physician Accoucheur to this Hospital, formerly of Middlesex Hospital, had not time during his visit to do more than read the paper and give me a verbal answer. He said, “I have no hesitation in saying that the saving would be certain and great.”

The Assistant Physician Accoucheur, who has until last week had charge of the medical patients here, as House Physician (Mr. H. L. Kempthorne), says, “The value of trained efficient nursing cannot be overrated in the management of acute diseases, and especially fevers, and would speak for itself in the saving of life, humanly speaking.

“In chronic cases, the eye of the trained nurse would soon detect the malingerer, and thus save the parish the expense of maintaining one who could well keep himself.

“In the prevention and amelioration of disease this plan would soon show its importance in the effects of cleanliness, ventilation, and other points carried out systematically and intelligently.

“The moral influence of the trained nurses by precept and example must in time diffuse itself through the medium of the pauper nurses to the paupers in hospital, the workhouse, and thence to the parish at large.”

I regret my inability to obtain fuller testimony to-day, but professional men are busy, and their visits to the hospital only on stated days.

If I can be of further use in any way, pray command me.

I am, Sir,
Very faithfully yours, (Signed) M. J. Superintendent of St. John’s.

After collecting and considering all the information within their reach, the Sub-Committee reported as follows:—

The Sub-Committee appointed on the 14th ultimo to consider and report as to a suggested alteration in the Staff of the Workhouse Hospital, report,

That the superiority, as nurses, of trained, experienced, and responsible women to the pauper women upon whom, under the present system, the actual nursing of the sick inmates of the workhouse devolves, is so apparent, that they conceive it to be unnecessary to offer any further observations upon this part of the subject. The points which have mainly occupied your Committee’s attention are the following:—

1. The cost of introducing a staff of trained nurses into the Workhouse Hospital, or any portion thereof. 2. The practicability of providing sufficient accommodation in the Workhouse for such an increase of officers. 3. The supply of trained nurses.

1. Your Committee are of opinion that the substitution throughout the Workhouse Hospital of trained nurses, for the present pauper nurses, would involve a direct expenditure of from 2,000l. to 2,500l. per annum. Should it be decided, in the first instance, to introduce the nurses into the male hospital only, it is probable that a sum of 800l. per annum would be found sufficient for the purpose. Evidence has been laid before the Committee to show that in those hospitals where the improved system of nursing has been introduced, the increased cost thereof has been more than compensated for by the saving, from the reduction of the time during which the patients are under treatment—the effect, as is alleged, of good and efficient nursing. Whilst your Committee admit the force of the argument, that if this be so in the case of hospitals, where the sick only are burdens upon the funds of the institution, much more must it be so in the case of the parish, where, as often happens, the whole family are chargeable upon the rates in consequence of the sickness of its head; they think it necessary to point out that one great difference between the workhouse hospital and an ordinary infirmary consists in this, that while in the latter (as a rule) none but acute and supposed curable cases are admitted, the former is, in many cases, the refuge of those who, as incurables, cannot gain admittance to other asylums. There can, however, be no doubt that the saving resulting from the rapidity and completeness of the cures effected by good nursing, will be a considerable set-off against the increased cost of the nursing staff; though your Committee can offer no decided opinion as to the probable extent of the saving so effected.

2. Your Committee believe that accommodation equal at least, if not superior, to that afforded to the nurses in the London hospitals, can be provided in the Workhouse at a moderate outlay. It is estimated that, for the male hospital, a sum of from 400l. to 500l. would suffice to provide the rooms and to furnish them.

3. With reference to the supply of suitable nurses, your Committee have to report that, as the authorities of the Nightingale Training School for nurses have offered to render to the Select Vestry all the assistance in their power in obtaining trained nurses, no great difficulty on this point need be apprehended.

Were your Committee as sanguine as some of the hospital authorities whom they have consulted, as to the happy results to be expected from the introduction of trained nurses into the Workhouse, they would at once, with the utmost confidence, recommend that the whole of the hospital should, at the cost of the parish, be supplied with this class of officers; but, looking upon it as they do, as an experiment (at least in its economical results), they unanimously recommend that the system should, in the first instance, be tried in the male hospital.

J. W. CROPPER, Chairman.

May 5, 1864.

The report of the Sub-Committee met with the approval of the Vestry. Some delay in the adoption of its recommendations was caused by a severe outbreak of fever in the town, which for the time absorbed all the resources of the Vestry and its officers. But on the 18th of May, 1865, a Lady Superintendent who had received a thorough training at Kaiserswerth and St. Thomas’s, twelve Nightingale nurses from St. Thomas’s, eighteen probationers, and fifty-two of the old pauper nurses were placed in charge of the patients in the male wards of the Workhouse Infirmary. By the judicious management of Mr. Carr, the most admirable arrangements were made for the accommodation of the nurses. Each superior nurse had a little room to herself, and the ex-pauper nurses were entirely separated from the other inmates of the Workhouse. It was hoped that by taking the best of the able-bodied inmates, separating them from the other paupers, and paying them small wages (say 5l. a year) they might be made available as assistant nurses, and that many of them might be elevated into independence and usefulness. It will be seen from the foregoing report of the Governor (p. 10), that he always distrusted this part of the plan adopted; and after the system had been at work a year, this attempt to utilize pauper nurses in a workhouse hospital was found to have utterly failed. It was proved that in a town like Liverpool, with very few exceptions, those able-bodied women only become inmates of the Workhouse who are either tainted in character, or are exceptionally ill-educated and inefficient. The experiment, however, was not wholly useless. It conclusively established two facts: that such women are utterly unfit to be trusted as nurses; and that their employment in that capacity does not effect all the saving that might be supposed. It might be thought that the choice lay between such employment and maintaining the pauper in idleness, while paying a nurse in her stead. But it was found—as the Governor had always predicted—that when sent back from the hospital to the able-bodied wards, nearly the whole of these women left the Workhouse, and relieved the parish from the charge of their maintenance. Many of these women, when employed as nurses, remain in the Workhouse for the sake of what they can pick up or extort. And moreover, when they left it, the training they had received, such as it was, rendered them more intelligent, and perhaps not more unreliable nurses than those usually employed by the poor. It is not unlikely that in country places the unfitness of able-bodied paupers to become assistant nurses may be far less than it has been found to be in a great seaport town like Liverpool. They may probably be less universally tainted in character, and after a year or two of employment as under-nurses they may be able to maintain themselves in that capacity out-of-doors, thus not only relieving the parish of their own maintenance, but assisting to diminish sickness and pauperism among their neighbours. The point is one which must be left to local knowledge and experience. It might be well, however, not to promise them payment till after some length of probationary service. It was always after pay-day that the ex-pauper nurses were most liable to get drunk and misbehave.[4] With the exception of the failure of the nurses taken from the pauper class, the first year’s trial was sufficiently successful to induce a continuance of the experiment. It was impossible, however, to judge the result by statistics. None that were available could be considered as an evidence of success or failure, for several reasons. The season was very unhealthy, and to relieve the pressure on the space and resources of the hospital, steps were taken to treat slight cases outside, as will be seen from the following extract from the Minutes of the Finance Committee, 24th November, 1865:—

“The district medical officers, Dr. Gee, Mr. Barnes, and the Governor of the workhouse being in attendance, pursuant to resolution of the Workhouse Committee at its meeting yesterday, the practicability of limiting the admissions to the Workhouse Hospital was considered, and the district medical officers were requested to co-operate with the relieving officers in limiting such admissions to those cases that cannot be properly treated outside the Workhouse.”