Subsidiary Notes as to the Introduction of Female Nursing into Military Hospitals in Peace and War

by Florence Nightingale

She should be effective, and enter the Pavilion about 6 A.M., go through the wards, read prayers in one by turns at the appointed hour, and give out the linen wanted. (Six is the nominal hour when the Head Nurses of one great London Hospital enter on their duty.) Here must be no nominal hours, all must be real, though not overstrained. Then the dressings, &c., attendance on Surgeons, &c. With 72 patients on different floors, she must train the Orderlies to do the lighter dressings (by training I mean real teaching, not leaving the Orderly to find them out himself); she must see all the wounds of all her wards which she does not dress herself at least every other day (which she can do by seeing some in the morning and some in the evening), and she must dress the heavy cases of all the wards herself. All this, with method, and not losing time by fetching and waiting, an efficient Head Nurse can do.

She must be responsible for the linen of the wards; but this must be simplified as much as can be, so as to secure responsibility, yet relieve the Nurse of unnecessary time spent over it.

The Nurse should be relieved of all writing and counting, on the score of loss of time incurred. It will not do to charge a Nurse, with seventy-two patients on three different floors, with serving each man his portion of diet; the diets of two wards would get cold while she was serving the first. It will be better to make the Ward-Master of Pavilion wards responsible for the serving the diets. There must, of course, be a card at each bed, or some other record, showing the diet the man is ordered. The Nurse must know at a moment’s glance what each patient is ordered.

The largest London wards are the two male accident wards in the London Hospital. Each Head Nurse has charge of five wards of 12 beds, separated (and in some respects impeded) by two lobbies. Very often there are fifteen beds in each ward (not by over crowding), and these Head Nurses are often to be seen in charge of seventy-five patients each, including many serious, and some urgent cases. The two lobbies, the small wards, and the duty of some daily writing and arithmetic in settling the diets, with some daily loss of time in fetching and waiting for medicine, render a Head-Nurse’s service, as regards “manual” labour, less efficient than it might be; even where she is most efficient.

Relieve the Nurses as much as possible of all writing and arithmetic. If it could be possible to relieve them altogether of the “settling” the diets, so much, by a great deal, the better. In the Lariboisière system, with one Nurse to each Pavilion, it is utterly impossible to prevent the Nurse losing daily time and strength on the stairs. But, relieved of writing, of arithmetic, of losing time by “settling” and fetching, such women as it will be our aim to procure can get through the duty of seventy-two patients, although with the serious drawback of their being in separate wards and on separate floors.

If, however, the Pavilion plan were so modified as to have two pavilions end to end, with an intervening staircase, so spacious and well ventilated as to cut off the ventilation of the two wards on the same plane, then all the conditions as to health, and facility of nursing and supervision, would be much more easily obtained. Of this more hereafter.

3. Responsibility of Nurse for Discipline of her Ward or Wards—how Modified in Military Hospitals.

3. As to the Nurse’s responsibility for the good order of the three wards in a pavilion, supposing the three wards are served by one Nurse, there must always be a clear difference between this responsibility in the Head Nurse of a Civil and a Military Hospital. The Civil Head Nurse, whose assistants are all Nurses, who with herself are under the Matron, is charged with, and responsible for, the good order of the ward, and it becomes her duty, the moment she finds herself unable to do this alone, at once to call in the Steward, or equivalent Officer, in whose hands is the police of the Hospital.

The Military Head-Nurse’s Assistants are Orderlies, i. e. men and soldiers, who, with the patients, are under military discipline. Of this military discipline, the military power from the Commandant down to the Non-Commissioned Officers acting as Ward-Masters, &c., is in charge; the duty of the Military Nurse is, I apprehend, in case of any insubordination which she cannot put down at once, to call in the Ward-Master or equivalent, before calling in the superior Military or the Surgical Officer; it being, however, well understood on all sides, that she has the right of direct appeal to the superior Military or the Surgical Officer, if the Ward-Master does not do his duty, or in the event of a grave irregularity, if he is not at hand, besides its being her duty to report such to the Matron, if the case admits of being deferred till that can be done. It is impossible to settle details until the regulations as to the new Hospital Corps are fixed; and whatever regulations, whether for Nurses or for Orderlies are made, some difficulty, and much discretion will be inevitable and necessary in working them. But it is necessary to bear in mind that whereas in the Civil Hospital the Head Nurse, under the control of, and responsible to, the Officers, including the Matron of the Hospital, is solely in charge of both the nursing and the discipline of her ward, both as to patients and as to Assistant Nurses; in the Military Hospital, she is in charge of the nursing, and the Ward-Master of the discipline, both of patients and Orderlies. To be in charge of the nursing, implies to have power to enforce discipline, but this is rather, in ordinary cases, to call in the military power, beginning from the lowest or Ward-Master’s grade and reporting this to the Matron, than to invoke herself the military superiors. Therefore it would be well worth while trying how far it would answer to serve the three wards by one Nurse, who, in each ward where she successively is, is bound, on perceiving any irregularity, to call in the Ward-Master, and, in contingencies, to appeal directly to the Surgeon and the Captain of Orderlies, and to make the discipline of the three wards the charge of the Ward-Master, who is bound to go through the wards when the Nurse is not in them. The Ward-Master, in order to fulfil his charge, must enter all the wards, while the Nurse is in one of them; so that the patients of one ward, who may know that they are safe from the Nurse for half an hour or more, as she is in another ward, know that they are not safe from the Ward-Master.

In a military Hospital we must bear in mind that it is essential that the discipline over patients and orderlies should be exercised by men, and that the Ward-Masters must be the lowest and immediate deposits of this power of discipline.