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WORKHOUSE NURSING:

THE STORY OF A SUCCESSFUL EXPERIMENT.

The accompanying account of the Improvements introduced by the Select Vestry of Liverpool into the Workhouse Hospital Wards under their control, may perhaps be interesting to you, and possibly might prove suggestive and serviceable, if similar improvements should be required in your district.

As the time and strength of the Lady Superintendent of the Nurses employed in the Workhouse Hospital are very fully occupied, enquiries or requests for further information should not be addressed to her, but to the Chairman of the Workhouse Committee of the Select Vestry ,

The following pages contain a brief account of the experiment successfully tried by the Select Vestry of Liverpool --the introduction of trained Nurses into the male wards of the Workhouse Infirmary. That experiment having resulted so successfully as to induce the Vestry to extend the system to the remainder of the infirmary, it may be interesting to those who are concerned in the management of workhouses elsewhere to learn something of its history and progress. It is the writer's object to explain--

The Liverpool Vestry had previously made considerable efforts to improve the workhouse infirmaries. The medical men had been encouraged to make requisition for every material appliance that could facilitate the cure of the sick; and paid female officers were appointed at the rate of one to each 150 or 200 beds, to superintend the giving of medicines and stimulants, and so forth: but of course so small a number, even had they been trained nurses, could do no real nursing, and could exercise little supervision over the twenty drunken or unreliable pauper nurses who were under the nominal direction of each paid officer. An appeal was made to the Vestry to consummate the good work they had thus partially commenced, and it was urged that Liverpool should assume the lead in the task of workhouse reform. The following considerations were submitted to the Select Vestry:--

"That Liverpool could commence this movement with great effect, and with the certainty that her example would be widely followed.

"That she had in times past taken a leading part in such reform. The introduction of the New Poor Law produced little change in Liverpool; so many of its wisest provisions were already in operation there, some of them for twenty or thirty years.

"That she had already established a system of attention to the sick poor in their own houses, which, if only by restoring heads of families to health and work, saved the parish many times the sum that it cost to private benevolence.

"That, lastly and especially, the proposed reform ought to commence in Liverpool, because in her workhouse the guardians had already, by their liberality, provided the sick with everything in the shape of diet and medical comforts that could conduce to recovery; and what was now wanting to give effect to their wise benevolence was, that their system should be administered and their intentions carried out by efficient and reliable nurses, in the stead of unreliable paupers."

The appeal further urged that--

"Successful efforts have been made in many directions to improve the nursing of the sick, and the workhouses must soon be the object of similar endeavours. Those poor sufferers whose disease is protracted and hopeless are refused admission into ordinary hospitals, and must come to the workhouse; and the mere duration of the illness is in such cases sufficient to reduce to poverty the most industrious, careful, and temperate--men who, while they could work, paid regularly their contribution to the poor-rate. Surely, these are entitled to at least as great care as that which sickness at once assures to the imprisoned felon, however criminal, for whom well-paid nurses are provided by the State.

"As to the other class of inmates of the workhouse infirmary--those whose ailments are curable--mere economy requires that the most efficient means should be taken to cure them as speedily as possible, so as to preserve them and their families from becoming paupers.

"Thus justice and expediency alike counsel the introduction into the workhouse of the best known system of nursing. Probably nothing which the skill and kindness of medical men can do, no food or physical appliances which the guardians can supply, no oversight or care which they, acting through pauper nurses, can bring to bear, are wanting in the Liverpool workhouse; but it is to be feared that much of this care, liberality, and thought fails of its object for want of a sufficient number of reliable and duly qualified nurses to carry out the instructions given, to administer food and medicine to the patients, to dress their wounds, and so forth."

This appeal was supported by two letters of Miss Nightingale and Sir John M^cNeill, G.C.B., President of the Board of Supervision .

My dear Sir,

I will not delay another day expressing how much I admire, and how deeply I sympathize with the Workhouse plan.

First let me say that Workhouse sick and Workhouse Infirmaries require quite as much care as Hospital sick. There is an even greater work to be accomplished in Workhouse Infirmaries than in Hospitals.

In days long ago, when I visited in one of the largest London Workhouse Infirmaries, I became fully convinced of this.

How gladly would I have become the Matron of a Workhouse.

But of a Visitor's visit, the only result is to break the Visitor's heart. She sees how much could be done and cannot do it.

Liverpool is of all places the one to try this great Reform in. Its example is sure to be followed. It has an admirable body of Guardians; it is a thorough practical people; it has, or soon will have again, money.

Lord Russell once said , that the Poor Law was never meant to supersede private charity.

But whatever may be the difficulties about Pauperism, in two things most people agree--viz. that Workhouse sick ought to have the best practical nursing, as well as Hospital sick--and that a good wise Matron may save many of these from life-long pauperism, by first nursing them well, and then rousing them to exertion, and helping them to employment.

In such a scheme as is wisely proposed, there would be four elements.

There is no reason why all these parts of the machine should not work together.

The funds are provided to pay the extra nursing for a time.

The difficulty is to find the Lady to govern it.

When appointed, she must be authorized--indeed appointed--by the Guardians. She must be their Officer; and must be invested by the Governor with authority to superintend her Nurses in conformity with regulations to be agreed upon.

So far, I see no more difficulty than there was in settling our relations as Nurses to the government officials in the Crimean War.

The cases are somewhat similar.

As to the funds, it is just possible that eventually the Guardians might take all the cost on themselves, as soon as they saw the great advantages and economy of good nursing.

If Liverpool succeeds, the system is quite sure to extend itself.

The Fever Hospital is one of the Workhouse Infirmaries. That is the place to shew what skilful nursing can do. The patients are not all paupers. How many families might be rescued from pauperism by saving the lives of their heads, and by helping the hard-working to more speedy convalescence!

Hopefully yours, FLORENCE NIGHTINGALE.

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:--

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.

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:--

STATEMENT AND QUESTIONS OF THE LIVERPOOL SUB-COMMITTEE.

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

The expenses 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:--

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