Read Ebook: Workhouse Nursing: The story of a successful experiment by Nightingale Florence Rathbone William

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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.

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?

REPLIES OF PHYSICIANS, &c. OF ST. THOMAS'S HOSPITAL.

"I have no doubt but that the plan suggested, if properly carried out, would be in the end a saving to the ratepayers, the restoration to health relieving the parish of constant burdens."

"I do not feel myself competent to measure at all exactly what might be the pecuniary result of the proposed system. But in my opinion the substitution of skilled for unskilled attendance would be of great advantage to the sick, and would of course tend to diminish that part of the pauperism which results from sickness."

"In my opinion the improved system of nursing recommended would amply repay the expense incurred."

"I believe that the introduction of paid nurses into the Liverpool Workhouse Infirmary would be of inestimable benefit to the sick poor received into the institution, and would thus amply justify the expense which it is proposed to incur. I also think it very probable that the cost of nursing would be repaid in many other ways to the ratepayers."

"I believe it would be quite repaid."

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

"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."

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 , 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.

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:--

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 , they unanimously recommend that the system should, in the first instance, be tried in the male hospital.

"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."

The endeavour to limit the admissions to serious cases would of course affect the returns, both as regards the time taken in curing, and the proportion of deaths. Even had there been no exceptional disturbing element, there is a defect in the statistics of workhouse hospitals which affects all inferences from them, in the absence of any careful classified list of cases kept by the medical officers, such as might fairly enable one to form a judgment from mere statistical tables. These, then, are not reliable as means of judgment, unless extending over a long period. The character of seasons, and nature of cases admitted, varies so much from year to year as to invalidate any deductions, unless founded on complete and minutely kept medical records. The following extracts, however, from the reports of the Governor, and the surgical and medical officers of the Workhouse, bear decisive witness to the value of the "new system," especially as contrasted with the "old system," which in 1865-66 still prevailed in the female wards. All these reports bear emphatic testimony to the merits and devotion of the Lady Superintendent and her staff. The medical men, it is noteworthy, speak strongly of the better discipline and far greater obedience to their orders observable where the trained nurses are employed--a point the more important because it is that on which, before experience has reassured them, medical and other authorities have often been most doubtful.

The main feature in the new system of nursing consists in the superseding of pauper nurses, and appointing in their places competent trained nurses from the Nightingale School. These latter to have the assistance of "probationary nurses," or in other words, women of intelligence and of good character desirous of entering upon the duties of nursing the sick as a profession. A third class was also created, designated "Assistants." These were selected from the old pauper nurses, and it was decided that they should be paid, clothed, and receive rations equal in quality and quantity to those issued to the officers of the workhouse. The nurses, probationers, and assistants were placed under the control of a "Lady Superintendent," who was empowered to employ them in the manner to her seeming best for the proper care of the sick.

The Committee will be prepared to hear that the change was immediately followed by the most marked improvement in every respect. The most casual observer could not avoid perceiving it. This applies not only to the state of the wards, the care of the sick, but is particularly observable in the demeanour of the patients, upon whom the humanizing influences of a body of women of character, devotedly discharging their duties, has produced evident fruits.

The question has often been asked whether the "new system is likely to succeed?" The "old system" meant nothing more than this, that old, ignorant, and unreliable pauper women, many of whom were of doubtful character, were entrusted with the discharge, without pay, of responsible duties. These have been displaced, and active, intelligent, reliable women, trained and skilled as nurses, with good characters and pay, have been appointed to supersede them. It would be a great discredit if these latter did not discharge their duties incomparably better than the former could do. That they do so I am happy to be in a position to testify.

In the opening paragraph of this report it is stated that "assistant nurses" were appointed and placed upon pay from the ranks of the paupers. This I was always opposed to. Their employment has resulted in complete failure, as the following figures will prove. The total number appointed to this date is 141. Of these sixty-seven have been dismissed through drunkenness and other misconduct, and sixteen have resigned; while it is positively true that there is not one of the whole number to whom I could entrust the duties of serving out wine or other stimulants, or, in fact, any duty requiring the exercise of integrity.

The experience of the past year renders it certain that the Poor Law, as now existing, offers no impediments to the successful working out of the most complete scheme for the efficient nursing of the sick, in the manner advocated by the best friends of hospital nursing.

GEO. CARR.

Sir,

With regard to the latter I can cordially bear testimony to their ability, and to their unwearied and uniformly kind attention to the patients under their charge. As to their nursing in its specific sense, I may state my belief that in every case my directions and those of the House Surgeons have been rigidly carried out. The medicines, stimulants, &c. &c. have been carefully administered, and the other numerous but less agreeable duties have been faithfully and efficiently attended to. Under their charge I have perceived a marked improvement in the demeanour of the patients--in fact, the discipline of the wards is completely changed. There has been no disorder or irregularity, but a sense of comfort, order, and quiet pervades the whole department. I believe further, that every patient leaving the wards has been more or less morally elevated during his location there.

Since my connexion with the hospital last August we have had somewhat approaching a hundred operations, many of them of a serious and dangerous character, requiring not only prompt assistance at the time, but most persevering attention night and day for a long time after. Almost all these operations have been in the male hospital, and I have no hesitation in saying that what success has attended them has been greatly owing to the most efficient assistance rendered by the trained nurses; and from my experience of the assistance received from the pauper nurses, in the few cases of operation performed in the female hospital, I should feel great diffidence in undertaking on that side such operations as I have had on the other side: indeed on one or two occasions the pauper nurses ran away, and when induced to assist were so nervous and frightened as to be of little service.

Persons of one class, as a rule, favour their own class, and there is a far better chance of double-dealers being detected when under the observation and care of a trained nurse, than when under the care of one of themselves. That such is the case my own experience testifies.

As far, therefore, as my experience extends of the system of trained nurses, whether regarding the saving of life, the restoration to health, or the relief of the suffering, it has been an undoubted success.

These reports were duly considered by the authorities; and after some discussion, it was resolved entirely to discontinue, in the male hospital ward, the employment of paupers as assistant nurses, and to substitute an additional number of probationers. A Sub-Committee of the Workhouse Committee was appointed to superintend and report upon the working of the system. These gentlemen devoted much time and attention to the subject, and at the close of the year undertook a minute inquiry into the operation of the old and new systems; examining personally the various officers of the Workhouse, from the Governor down to the pauper nurses in the female wards. Increased experience brought out in a yet stronger light the superior advantages of the employment of trained nurses. The very able, clear, and conclusive report of the Sub-Committee leaves little more to be said on the subject. It determined the Vestry to adopt the system in permanence, and to extend it to the whole of the Workhouse Infirmary, a year before the period fixed for the trial of the experiment had expired. It will be seen that the report of the second year's experience has a peculiar value, as bearing on the question whether, or how far, women may be competent to undertake one of the most delicate and difficult kinds of feminine work--one requiring special knowledge as well as special habits of punctual regularity, obedience, and thoughtfulness--without receiving any special training or education for such a duty. If the reforms about to be introduced into the pauper hospitals in London and elsewhere are not to end in failure and disappointment, provision must be made for training the nurses to be employed there, either before they enter the hospitals or within them.

The report of the Sub-Committee of Superintendence is as follows:--

The Special Committee on Nursing, pursuant to resolution of the Workhouse Committee of the 7th of March instant, report,

Of the character of the nursing in this portion of the Workhouse, your Committee have heard but one opinion. The Governor and the Medical Officers concur in speaking of it in terms of the highest praise, and throughout the whole period during which the Committee have superintended it, no single circumstance has come to their knowledge calculated to make them speak of it otherwise than in terms of approval.

The nursing of the women's wards continues to be done by paupers under the superintendence of paid officers. The superintendence of these officers is of necessity very imperfect, as not only has each charge of from 150 to 200 patients, but these patients are located in several rooms, each ward containing about twenty patients. The only portion of the nursing, properly so called, which these officers undertake, is the administration of stimulants and in some exceptional cases of medicine. The bulk of it, as the giving of medicine, the dressing of wounds, the distribution of food, is left to be done by paupers. So much has from time to time been said of the untrustworthiness of pauper nurses, of the evils resulting to those patients who are placed exclusively under them, of the mischievous consequences upon the discipline of the Workhouse of a large number of petty offices being filled by able-bodied women, that your Committee believe they rightly interpret the feeling of the Select Vestry, as they undoubtedly do that of the general public, in supposing that the actual nursing of the sick in the Liverpool Workhouse can no longer be left in the hands of pauper nurses.

Starting from this point, your Committee considered that they had principally to inquire what sort of nursing can be most advantageously substituted for that of nursing by paupers. Two courses only appeared to be open to them--either to increase the number of paid officers, giving to each such a number of patients as she could reasonably be expected to look after, and treating each as an independent officer; or to extend over the whole hospital the system now in existence in the men's wards. Your Committee were much aided in forming a judgment upon this point, by what has taken place during the last few months in the fever hospital.

Here, originally, the paid attendants were in precisely the same position, with precisely similar duties as the paid officers in the women's hospital; but the number of patients rapidly diminishing, and no corresponding reduction taking place in the number of officers, the staff was so large that Dr. Gee felt able to call upon the officers to act as nurses. The result was what might have been anticipated, that although an improvement upon the old system of nursing by paupers was perceptible, the state of the nursing was still far short of the standard reached in the men's wards.

The officers were told to nurse, and they did their best, but never having themselves been taught, their attempts in a great measure failed; they were paid and retained as nurses, without being efficient nurses.

Your Committee therefore recommend that as soon as the requisite number of trained nurses can be procured, the nursing in the women's hospital, and afterwards in the fever hospital, be placed in the hands of trained and skilled nurses, acting under the direction and control of Miss Jones, the present Superintendent. The expenses attendant upon the necessary increase in the number of nurses will not be great, as all that will be necessary will be to convert two of the rooms now used for sick boys into sleeping apartments for the nurses. In making this recommendation, the Committee are glad to know that they are fortified by the unanimous opinion of the Governor and the Medical Officers of the Workhouse.

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