Subsidiary Notes as to the Introduction of Female Nursing into Military Hospitals in Peace and in War. (continued 2)

(3.) The great Charité Hospital, the town-hospital for 1,200 patients, spite its French name. It consists of two buildings; the old one, used in winter; and a splendid new one, into which all the patients, except the lunatics and the small-pox and the venereal cases, are moved for the six summer months. The flooring throughout is of the same wood (deal) as at Bethanien, but has much more laque. The more laque is used, the brighter the floor shines, but the sooner it requires re-oiling and laque varnishing. The Charité floors are re-oiled with laque every year; they are cleaned in the same way as at Bethanien, only with more dry rubbing. On bad days, when the numerous students have passed through, the ward floors occasionally require to be cleaned; but, in general, even on these occasions, it is enough to sweep them, and to clean the next morning as usual.

(4.) The principal Military Hospital, the Garnison Lazareth in the Hirsch Allée, for 800 patients, usually not filled. The flooring is the same as at Bethanien, except that no laque is used. It is oiled generally, not always, yearly.

The Ober Inspector, a Landwehr civilian, who is supreme over the Hospital, and an Ober-Stabs-Arzt, both speak very strongly as to the superiority of this flooring over all others for Hospital use, and in particular over flooring which requires scrubbing. It has only been introduced of late years. They consider it equal to any amount of hospital wear and tear. The military patients, like those of the Charité, Bethanien, and St. Hedwig’s, wear hospital slippers, with soles thick enough to admit of their walking in the garden, when fine; when not fine, they are not allowed to go out. This flooring would not stand the constant tread of nailed shoes. But often, on bad days as on fine ones, great numbers of soldiers come to visit their sick comrades, and leave the floor very dirty; generally it is enough to sweep the floor after the visitors are gone, and to clean it as usual next morning; sometimes it is necessary to clean it the same afternoon.

The flooring is cheap. Somewhat more expense attends laying it down than the ordinary boards, and a certain expense attends the re-oiling, but the constant outlay for soap and soda is entirely saved, except a little soda in the grand annual purification, with hot water, in addition to the daily one with cold; the time and labour attending scrubbing is saved, and above all the great gain to the sick arising from its use is secured.

The strong, decided way in which the old grey-headed Army Surgeon, and the middle-aged business-looking Civilian, spoke of the merits of this flooring, and of its capacities, was exceedingly satisfactory.

(5.) Two years ago the greater part of the boards in the Kaiserswerth Institution, which are of deal, were oiled, both on sanitary grounds, and to rid the Sisters of the drain on time and strength in scrubbing. They are considered far preferable to the old ones, and to answer in every respect. Yet the Kaiserswerth floorings would not answer the English requirement of extreme cleanliness. They are substantially clean, but, like those of the Military Hospital of Berlin, it takes examination to ascertain that they are so, and from the same cause—there is no “laque.” Also the colour is not at all so agreeable as the Bethanien colour. These oiled boards last a year only. A moderate amount of laque is required to add to their durability.

The sum of the information, condensed as much as possible, on this subject is;—

I. The boards, which are always of deal, can be prepared in three ways:

(I.) Laquering, only suitable for reception rooms, or when by some chance a ward is wanted to be got ready in a hurry; it takes less time; after two or three days, the room or ward can be used, and it shines brighter, but it lasts a much shorter time than the other procedures, as it stands less the incessant treading incident to all ward floors; it is also more expensive. Let us consider it wholly unsuitable for wards.

(II.) Oiled boards, with more or less laque.

The Charité boards have a great deal of laque.

The Bethanien and St. Hedwig’s boards much less.

(III.) Oiled boards without any laque—

As in the Military Hospital.

II. Much laque makes the floors shine brighter; requires more time to clean them; and earlier re-preparation than where less laque is used.

The Charité boards would be unmeaningly splendid for an English Hospital, and quite out of place in a Military one; besides entailing some unnecessary annual expense, and some daily finicking care.

III. A small quantity of laque, as at Bethanien, gives an amount of polish to the floors, which enables the eye at once to ascertain whether they are clean or not; considerably improves the appearance of the floor; and, according to all high authority, adds both to the durability of the floor, and the healthiness of the Hospital. It renders the whole flooring less subject to cracks, to dirt and dust getting into holes and corners; and, above all, by filling up the grain of the floor, it prevents the saturation, by organic matter, which otherwise takes place and which scrubbing only makes more mischievous.

IV. Where no laque is used, the absence of all polish on the dark-brown floors makes examination necessary, to see whether they are thoroughly clean or not. This flooring would never satisfy the eye or the mind of an English Inspector-General or Surgeon. But the main objection to the absence of laque certainly consists in the sanitary one above stated.

V. All the various authorities agree in estimating very highly the superiority of this flooring to flooring requiring scrubbing. They all agree in their reasons for this preference, viz.:—

(I.) The dampness which remains in a ward more or less time after it has been scrubbed, is completely avoided.

(II.) The tendency to miasma is greatly counteracted, both by getting rid of the damp, which encourages and spreads the exhalation of the organic saturations; and by making the floor impervious, preventing dirt, and with dirt miasma, finding its way into holes, chinks, and corners of the floor.

(III.) The mode of cleaning this flooring, while it avoids damp, daily purifies the ward air.

(IV.) The floor, and its mode of cleaning, get rid more than by any other way of dust, and of the miasma dust often conveys.

(V.) The time, labour, and expense of scrubbing are saved.

(VI.) The Berlin authorities consider that these oiled boards, with a small quantity of laque, are, on the whole, decidedly cheaper than the common boards; that the boards last rather longer; and that the avoidance of scrubbing saves more than the extra preparation and its renewal cost, apart from the sanitary gain.

VI. Against these advantages, the following disadvantages are to be placed:

(I.) This flooring shows where most used, instead of the uniform appearance of the white scrubbed boards.

(II.) Scratches show, and remain upon it; so all furniture must be lifted, not dragged over it.

(III.) The tread sounds a little more, little, but more, than on white boards.

(IV.) It would not stand the constant tread of nailed shoes; and patients of a ward so floored, ought to wear slippers with moderately thick soles. (The German Doctors consider the use of slippers preferable to that of shoes, by the patients, as keeping a ward much quieter, cleaner, and disturbing the severe cases less.)

(V.) Carpets could not be nailed on it, as the floor should be daily cleaned. Several Hospital authorities whose rooms are thus floored, have large pieces of carpet round the furniture most used, bed, tables, sofas, &c.; these are daily taken up and dusted while the floor is being cleaned. To many English minds, the sight and feel of a carpet is essential to the idea or feeling of comfort; and it might be sound policy, in the event of a trial being made of this flooring, to leave the Officers, Military and Medical (I do not mean patients), in possession of scrubbed rooms and carpets. The Superintendent might have one or two pieces of carpet for her rooms; and the Nurses should dispense with carpet.

Both in the new part of the Charité and at Bethanien, long broad corridors run along the back of the wards which open into them. The corridors are floored like the wards. In those of the Charité a piece of long carpet is laid in the midst of the corridors, where patients walk not a little. At Bethanien, a long piece of matting is laid in the midst of the corridors, where the patients walk freely. Carpet of either kind is not considered to benefit the floors, but to diminish the noise. In the wards of Guy’s Hospital, for the same reason, a long piece of matting is laid along the middle of the floors.

VII. This flooring is unsuited for stairs, though so used in some Hospitals, as, in case of fire, oiled wood would burn rather quicker than common wood. Hospital stairs should be of stone.

VIII. It is also unsuitable for kitchens, wash-houses, water-closets, and sinks. The floor round a stove or fire-place in a ward or room should be protected by a strong plate of lead or tin.

It might also be as well to floor operation-rooms with flooring, admitting of scrubbing, because these oiled boards do not well stand sand or bran, and our Surgeons might be discomposed at missing one or other of these things. Sand or bran mixed with blood would make a mess, the traces of which would show a little on this flooring. For the rest, it is particularly easy to wipe blood off it. After each operation, one or two minutes, a wet cloth of the kind here mentioned, and a broom, remove the blood that has fallen, and leave a clean floor; or if there has been a very great mess, five minutes, a wet cloth to lap up the blood, &c., another wet cloth, a pail, and a broom, do all: after the operations are over, a few minutes’ whole or partial cleaning, as the case may be, make all tidy again. Still, many English Surgeons expect to have sand or bran thrown on the floor before, or just after the first blood has fallen, and might object to standing some minutes on the bloody floor, which spoils boots, &c. Red floorcloth, of sufficient size, round the operating-table, might answer every purpose.

IX. On laying down the oiled boards for the first time, six weeks should pass after the oiling and laquering before the ward is inhabited.

X. After subsequent re-preparation of the floors, the longer the wards are left vacant the more the floor both hardens and shines; but for practical purposes the interval of a fortnight is enough.

XI. The flooring, so prepared, or re-prepared, ought, on an average, to last about three years. In case of any extra miasma, it is often desirable to hasten the re-preparation, and to have it done after two years’ use. To do it annually is, unless in some emergency, quite unnecessary.

Although the process cannot be said to be by any means perfect, on account of the deficient durability of the surface, it would be well worth while to try it in England, and, if it answers and if it were improved, the sick would gain much, and the Hospital staff would gain much—the latter much more even in Civil, than in Military Hospitals.

But it would be incurring a great responsibility to have the whole of a large new Hospital floored in this way, because,

I. An English climate has made, and makes, so many things which are good and suitable abroad, unsuitable and sometimes pernicious for England.

II. Our coal-fires, whether assisting or assisted by our atmosphere, certainly give us an amount of soot and dirt unknown abroad. At Berlin, all fire-places are stoves, where sometimes coal, sometimes coal and wood are burnt.

This flooring might not stand well either the damp climate, or the smoky atmosphere and amount of flying soot of England: but it would be well worth trying; as also trying to improve it.

By all accounts, a great deal depends upon the manner in which these boards are prepared; a little more or a little less, whether of oil or laque, makes a great and lasting difference. It would never answer to make an English carpenter or painter do this from written or printed directions.

If we obtain a trial of this floor—the best course would be, to let an English carpenter prepare a number of boards and skirtings, of due size, suitable for the new flooring of some few wards in one of Her Majesty’s hospitals, which requires new flooring; then to desire either the proper tradesman, or the Queen’s Minister at Berlin, to order the house-painter, Schonby, No. 5, Michael Kirchplatz, Berlin, to send an experienced, trustworthy foreman, with the proper tools and materials, and for this man, with a complement of English workmen, to prepare the boards.

The mode of cleaning is extremely simple, though of course there is a knack to be learnt; and, like everything else, it can be done well, indifferently, or ill. Any English man or woman accustomed to cleaning would understand the thing in one morning, and would, if he or she opened instead of shutting the mind to the outlandish thing, be proficient in it in a week. All these things sound abstruse on paper, and are far more simple and more easily learnt by seeing done than by reading. The foreman ought to give one or two lessons to one or two Orderlies, or Nurses, as the case may be.

14. Ventilation of Wards.

14. Ventilation.—The amount of fresh air required for ventilation has been hitherto very much underrated, because it has been assumed that the quantity of carbonic acid produced during respiration was the chief noxious gas to be carried off. The total amount of this gas produced by an adult in 24 hours is about 40,000 cubic inches, which in a Barrack room of 16 men would give 370 cubic feet per diem. Allowing 8 hours for the night occupation of such a room, when the doors and windows may be supposed to be shut, the product of carbonic acid would be 123 cubic feet, or about 15½ cubic feet per hour. This large quantity if not speedily carried away would undoubtedly be injurious to health; but there are other gaseous poisons produced with the carbonic acid which have still greater power to injure. Every adult exhales by the lungs and skin 48 ounces or 3 pints of water in 24 hours. Sixteen men in a Barrack-room would therefore exhale in 8 hours 16 pints of water and 15½ cubic feet of carbonic acid in the atmosphere of the room. With the watery vapour there is also exhaled a large quantity of organic matter ready to enter into the putrefactive condition. This is especially the case during the hours of sleep. And as it is a law that all excretions are injurious to health if reintroduced into the system it is easy to understand how the breathing of damp foul air of this kind, and the consequent reintroduction of excrementitious matter into the blood through the functions of respiration will tend to produce disease.

This will be still more the case in sick wards overcrowded with sick, the exhalations from whom are always highly morbid and dangerous, as they are nature’s method of eliminating noxious matter from the body, in order that it may recover health.

A much larger mass of air is required to dilute and carry away these emanations than is generally supposed. And the whole art of ventilation resolves itself into applying in any specific case the best method of renewing the air sufficiently, without producing draughts or occasioning great varieties in temperature.

When the question of ventilation first assumed a practical shape in this country, it was supposed that 600 cubic feet of air per hour were sufficient for a healthy adult, in a room where a number of people are congregated together. Subsequent experience however has shown that this is by no means enough. As much as 1,000 cubic feet have been found insufficient to keep the air free from closeness and smell; and it is highly probable that the actual quantity required will ultimately be found to be at least 1,500 cubic feet per hour per man. In sick wards we have more positive experience as to the quantity of air required to keep them sweet and healthy. It has been found in certain Parisian Hospitals, in which the ventilating arrangements were deficient, that pyœmia and Hospital gangrene had appeared among the sick in consequence. These diseases disappeared on the introduction of ventilating arrangements, whereby 2,000 cubic feet of fresh air per bed per hour were supplied to the wards. Notwithstanding this large quantity, however, the ward atmosphere was found not to possess sufficient freshness or purity: and the quantity of air had to be increased in subsequent ventilating arrangements. As much as 4,000 to 5,000 cubic feet per bed per hour have been supplied in certain Hospitals. At the rate of 4,000 cubic feet, the ward atmosphere is found perfectly fresh.

Night Ventilation.

At one of our largest London Hospitals it will be perceived that above the one door of each ward is a large ventilator, ordered to be open day and night—that beyond this ventilator, which opens into the landing-place, is a large window which opens into the external air; and thus admits fresh air into the ward at night, diminishing the foul night atmosphere. This night ventilation system is good; but it requires careful watching, as chilly patients, Nurses, and sometimes Sisters, are very apt to give, after they conclude the rounds are over for the night, a sly pull at the rope and to shut the window, and thus imbibe the foul air directly generated, in quiet.

Special Wards, whether desirable or not.

15. Special Wards.—It may be laid down as an axiom in the management of sick affected with certain zymotic diseases, such as fevers, cholera, dysentery, &c., that they should be distributed over a wide superficial area, and have a large allowance of cubic space. Agglomeration of such cases in small ill-ventilated wards is quite sufficient of itself to occasion a high proportionate mortality among the sick. In mild climates and seasons very little protection is necessary from the change of temperature; so that the sick from epidemic diseases can be camped out and exposed to the full influence of the atmosphere, not only without danger, but often with great benefit. It is only when the temperature is low and variable, and the season inclement, that danger is likely to accrue from this exposure. And hence the necessity of inquiring how we can best combine the requisite elevation of temperature and the most suitable amount of cubic space and ventilation for the treatment of these diseases in Hospitals.

Medical Men generally are satisfied that these ends cannot be safely arrived at by agglomerating sick in fever wards in Hospitals. And hence has arisen a practice, which experience appears to have approved, of intermingling a small number of fever cases in wards containing a certain number of sick from other diseases. The practice appears to be not only perfectly safe, but advantageous for the sick. It is known, however, that if the proportion of fever cases exceeds a certain number, the other cases in the ward are apt to become affected with fever. It would appear as if, so far as the fever is concerned, the cubic space occupied by other diseases was to a certain extent available for the use of the fever cases. But the proportion of such cases, that can be advantageously placed among the general sick of any ward, will depend upon the size of the ward, the means of ventilation, the number of cubic feet per patient, the position of the windows, the exposure of the building, and other similar circumstances.

Again, it is doubtful whether the preservation of an uniform temperature in any Hospital, even in one set apart for chest complaints, is beneficial for the sick, or whether it be beneficial to agglomerate consumptive cases, without very special precautions, under the same roof. Without discussing the validity of the opinions held in Southern Europe as to the contagious nature of consumption, it may be very fairly doubted whether a number of cases placed under a common roof, and breathing a common atmosphere, would not yield a higher rate of mortality than the same cases would do if distributed through the wards of a well-ventilated Hospital, among other diseases.

The subject is worthy of examination. At all events the phenomena observed in this disease in the warmer climates of Europe have led to the popular belief above stated; and it would appear to point to a higher rate of mortality as a not unlikely result of the establishment of special Hospitals or wards for consumptive diseases, unless extraordinary care were taken to ventilate them properly, and to imitate the natural variations of temperature which appear to be necessary for recovery.

16. Proposed Regulations as to Payments, by Superintendent-General.

16. All salaries and wages of Matrons and Nurses should be paid, on the Superintendent-General’s order, from the Hospital chest, to the Matron, who should pay the wages and other expenses of the Nurses, and account for all monies received by her on such orders. All outfits and travelling expenses, in cases of transfer, &c., should be provided on the order of the Superintendent-General.

Opinion as to Superintendent-General paying Wages and Salaries.

There would be considerable difficulty in the way of making all payments at a distance to Nurses, direct from the Superintendent-General, otherwise than by orders on the Hospital chest or Treasury. But there can be no doubt that the Nurses ought to be paid by the Matron and by no one else. The service of Nurses in Hospital is a peculiar service, and if not successfully conducted by influence never can be by coercive discipline. It would be a great mistake, therefore, to throw away any means of influence which we can command, and the “eye of the maid-servant is to the hand of her mistress” now as it was 2,000 years ago. The fact of paying and being paid helps greatly to establish the proper mutual relations between the superior and the subordinate. The Matron would draw from the Hospital Treasury, on the orders of the Superintendent-General, and would account to her. As a matter of discipline, it would make no material difference whether the orders of the Superintendent-General, in favour of the Matron, for the pay of the Nurses, are cashed by the Hospital Treasurer or by a banker, always supposing that the Treasurer is bound to honour those orders, as any other banker would.

Matrons abroad may dismiss Nurses under appeal.

The Matron, in any Hospital out of Great Britain and Ireland, should be able, with the concurrence of the Governor of the Hospital, to dismiss and send home any Nurse; or the Governor himself, on his own responsibility, may direct the Matron to do so, under appeal, however, in either case, to the Superintendent-General, who shall decide, after the arrival of the Nurse, whether she is to be dismissed or whether she may be placed in another Hospital.

It should be secured, not left to chance, that the Matron be immediately made acquainted with any complaint of the Medical Officers against a Nurse.

Matron to draw Rations and Extras.

The Matron should be able to draw from the Purveyor, on her own indent, with the sanction of the Governor of the Hospital, such rations and extras as she may consider necessary for the Nursing establishment, and make the arrangements for cooking. In the United Kingdom the Matron should be able to make arrangements, subject to the approval of the Superintendent-General, for commuting rations for mess-money, not pay.

The Governor is responsible for the sufficiency of all supplies and none ought to be expended, without his sanction. This might be indispensable, if there were danger that supplies might run short.

Opinion as to Governor’s jurisdiction over Nurses.

Upon both these latter points, supposing the Governor of a General Hospital to exist, he must have power to maintain the discipline of the Hospital, in all its Departments, as a General commanding a division has, in regard to every regiment composing it. But he ought to exercise it only through the Matron, as commanding a corps. He must also have power to require the exclusion from the Hospital of any Nurse whose conduct he may find to be inconsistent with maintenance of discipline, and this power he would enforce, on his own responsibility, by directing the Matron to remove the offending Nurse from the Hospital. The conduct of the Nurse would become the subject of investigation afterwards, in terms of the established regulations. But practically such a case could hardly occur, unless by the fault of the Matron, who would, of her own accord, desire to remove a Nurse, on being satisfied that such a measure was necessary or expedient. It would be proper, too, both for her own justification and for the maintenance of the Governor’s supremacy in the Hospital, that the Matron should obtain his concurrence in the removal of a Nurse from the Hospital. The proceedings, in all such cases, would, of course, be reported by the Matron to the Superintendent-General.

Whether the Governor has the power of removing the Matron, who clearly and properly ranks among the officers under him, should be settled and not left to be disputed about in a distant station. At all events, if he has this power over her, it must be guarded, as extending only to suspension from office, in cases of alleged flagrant neglect or misconduct, till the whole matter can be remitted and decided on by the Superintendent-General.

17. Nurses’ Wages.

17. Generally, as to the question of wages and pensions, a regulation that Nurses shall have a small annual increase of wages is better than one giving an increase after five or three years.

Efficiency of Nurses does not increase by springs and starts, like Grasshoppers.

Efficiency does not go by starts and springs, like grasshoppers, but makes “a small annual increase,” like the wages proposed.

Nay, I appeal to everyone with experience in these matters whether the greatest improvement is not made the first year, the second year a little less, and so on the third and fourth, till, when the fifth year comes, if improvement has not been made by that time, it never will be.

The first five years a constant improvement. Afterwards if there has not been improvement made before, no hope at all.

For trust-worthiness is the true efficiency of a Nurse. And it may safely be said that, if by the end of the first year she has not improved in trust-worthiness, she had better go; and if she have not almost reached her culminating point by the fifth year, she certainly will not improve afterwards.

Three principles in Wages.

The reasonable principle I believe to be, 1, to begin improving the wages at as early a period as possible; 2, to let them increase till the Nurse reaches her maximum of efficiency; and, 3, after that to make no more increase.

By rate of Wages to retain those who are efficient.

Because the object is to induce the young and efficient women to stay, not the old ones. They will stay long enough, because the old ones nobody else will take.

By rate of Pension to reward those who have been efficient.

The rate of pension ought, on the other hand, to increase with the number of years’ service, and continue increasing till the end. The principle of pensioning is different from that of wages. After the woman has reached her maximum of efficiency, which certainly will be not later than forty-five, probably not later than forty years of age, the inducement to stay should be the improvement of pension. This compensates for any apparent injustice in the first principle towards an old servant.

Civil Service an Example.

No other system appears to be founded on common sense; and it is one generally acknowledged in the Civil Service, where salaries are made to rise as soon as possible. Military Hospitals must not be made training schools for Nurses; else it would be better to admit them much younger than at the age of thirty years.

Opinion as to Wages and Pensions.

If a Nurse cannot enter the Service till after she is thirty, the majority will no doubt be some years above thirty when they enter, say an average of thirty-five; and five years appear a very long probation for a person at that age before increase of wages begins. In most cases, in Civil Departments, there is only one year of such probation before increase begins, though the persons are much younger when they enter. A maximum might be fixed, beyond which the wages should not rise, and when the increase of pension would be sufficient inducement to remain. Very few Nurses can be expected to continue really efficient till sixty years of age; but it is often difficult to say that a person is disabled, though she may have become less active and efficient. If there is no retiring allowance there will be great reluctance to dismiss her, and it might, in that case, be cruel. The better plan would be to promise a small pension after ten or twelve years’ service, on a scale so graduated thereafter as to offer an inducement to remain, at the same time that it would afford facility for enforcing retirement without injustice. This would be economy. The “Nursing Sisters” grant £20 after twelve years’ service.

After a time there may probably be difficulty in dismissing persons who have done good service for ten years, but have declined in efficiency, unless there is a retiring allowance. They may be reluctant to retire; and, if so, it would be almost impossible to dismiss them, without some kind of provision. This is a difficulty which is encountered in every employment in which there is no such provision. Persons who can hardly be said to be disabled but who have become less efficient are retained, because, if dismissed, they have no means of livelihood.

I have consulted the best authorities upon these points; and I find the following general principles admitted:—

General Principles as to Wages and Pensions.

(1.) Same Salary at first.

(1.) At whatever age a Nurse enters the Service she shall begin with the same salary.

(2.) Same Annual rate of increase.

(2.) The annual rate of increase shall be the same for all ages of entrance.

(3.) Maximum Salary fixed.

(3.) The maximum salary shall not exceed £ .

(4.) Pension for Service after Ten Years.

(4.) The pension for service shall not begin until ten years of completed service.

(5.) Amount of Pension a certain Percentage on mean Salary of preceding year.

(5.) The amount of pension shall be a certain percentage on the salary during the year preceding that on which she is pensioned.

Applications of the foregoing Principles.

(1.) Annual rise of Wages till the maximum of efficiency.

(1.) That the wages of Nurses shall rise annually, for a definite number of years, attaining their maximum, on an average, at the age forty-five, when the Nurses are found to be most efficient.

(2.) After five years’ Service Pension for Disability.

(2.) That, after five years’ service, the Nurse shall, in the case of ABSOLUTE DISABILITY, become entitled to a pension during the period of her disability.

(3.) Pension on a Scale graduated on the Wages.

(3.) The pension will be on a scale graduated on the wages. It will be twenty per cent. of the annual wages in the year of service, 5–6, and the rate to be granted will rise progressively two per cent. per annum, until the rate on the wages becomes seventy per cent.

(4.) All Nurses to retire at Sixty.

(4.) All Nurses will be placed on the Retired List at the age of sixty.[16]

(5.) Nurses to serve again who are Pensioned for Disability, when Disability ceases before Sixty.

(5.) Those Nurses who are pensioned at an earlier age, for disability, will, if called upon, be liable to serve when that disability ceases, or to forfeit their pension. They must therefore bring an annual medical certificate of disability to the Superintendent-General, in order to receive their pension.

(6.) Nurses partially Disabled to receive partial Pension.

(6.) Nurses who are partially disabled will only be entitled to a certain proportion of the pension allowed in the scale, to be determined, on representation made by the Superintendent-General.

Example.

Example.

Age.Completed Years of Service.Wages.Pension.

300£20?Gratuity

31122Gratuity

32224Gratuity

33326Gratuity

34428Gratuity

35530 × ·2 =£6

401040 × ·312

451550 × ·420

502050 × ·525

552550 × ·630

603050 × ·735

These principles, if admitted, would suggest the following heads for regulations as to Nurses’ wages and pensions:—

(1.) Amount of Wages, first year, £20.

(1.) At whatever age a Nurse enters the service, the amount of wages paid to her during her first year of service, will be £20.

(2.) Annual rate of increase up to £50, when it ceases.

(2.) There will be an annual rate of increase of wages equal to 10 per cent, of the first year’s wages, until the yearly wages amount to £50, beyond which there will be no further increase.

(3.) No Pension till Ten Years’ Service completed, nor for Disability till Five Years.

(3.) A pension will be awarded for service to any Nurse, who may retire, on account of age, at the expiry of ten full years’ service, but in case of disability, a Nurse shall receive a pension after five years’ service, or a gratuity, according to circumstances, if discharged for disability, before she has completed five years of service.

(4.) Rate of Pension.

(4.) Rate of Pension. The pension will be on a scale graduated on the wages. It will be 30 per cent. of the wages received by the Nurse in her tenth year of service, and the pension granted to Nurses who have served more than ten years, will rise at the rate of 2 per cent. of the wages for every additional year of service, until the pension amounts to 70 per cent. of the wages received during the year preceding its grant, beyond which no higher pension will be granted, except in cases of special devotedness to the public service, when an addition to the regulated rate of any pension may be granted on special recommendation, made by the Superintendent-General of Nurses, setting forth the nature of the service for which such augmented pension is to be granted.[17] But no such pension shall exceed the amount of £50.

(5.) Nurses, Pensioned for Disability, whose Disability ceases, may be called on for Service.

(5.) Any Nurse pensioned for disability, may be called on for service in the event of such disability ceasing before the age of sixty, in which case her wages will be the same as they would have been, had she not been disabled.

(6.) Every Nurse who has completed her sixtieth year, must retire from the service on her rate of pension.

(7.) Any Nurse, temporarily or permanently disabled in the service, who has served more than five and under ten years, will be entitled to a lower rate of pension, according to the circumstances of each case, as represented by the Superintendent-General.

18. Number of Nurses to Patients.

18. Nurses should be selected and appointed by the Superintendent-General of Nurses for each General Hospital, in a proportion not exceeding one nurse for every twenty-five cases.

There is nothing so fatal to discipline as to require by regulations what it is known and admitted cannot be performed. Such rules are made to be broken. Therefore, is it not better, instead of fixing a number to fix a limit, and say “not exceeding one to every 25 or 30 patients,” leaving it to the Superintendent-General to economize Nurses, and not appoint the full number permitted, unless when really necessary? In one case she might consider one nurse for fifty or even sixty sufficient; in another, one for every twenty-five might be few enough. Why tie up her hands against economy as well as against extravagance?

At the same time it is necessary to state—

(1.) That, by all accounts, at home and abroad, in the English and in foreign armies, the proportion of severe cases is very considerably less, in time of peace, in a Military Hospital than in a Civil one, especially in the surgical wards.

(2.) That the Nurse’s time, being relieved of the waste incurred by fetching and waiting for things, the cleaning of the ward being done by Orderlies, and, an important item, the Ward-Master being responsible for the serving the patients’ food, twenty-five sick are not enough, on an average, to occupy, properly, her time.

(3.) That idleness, always pernicious, is never more so than to Hospital-Nurses.

(4.) That petting the patients, by way of filling up time, would be, of the two, more pernicious than idleness.

(5.) That it is most important, apart from these reasons, to train and accustom these Nurses to serve efficiently large numbers of patients, so as to make them useful in war-service, where every woman who can be spared is better away; and where a small efficient staff would, please God, do excellent service.

(6.) That it is not in human nature, taking its average, supposing the Regulations lay down that the proportion is not to exceed 25, for many Nurses not to murmur at having more; whereas they ought from the first to understand, that the service is a very laborious one, and that none but women able and willing to undergo and render laborious service, ought to enter it, or be suffered to remain in it.

(7.) Care must be taken therefore that in fixing this minimum, no use may be made of it dangerous to the service, either in the Hospital work itself, or in provoking adverse criticisms upon these Regulations in quite different places. Twenty-five cases are not generally enough.

19. Precautions in sending Nurses abroad.

19. It would be expedient to take the advice of an able and honest man of business as to whether the Superintendent-General should, on engaging a Matron or Nurse, have her signature to a bond or not. On the one hand, we know what bonds are to loose consciences, and if the promulgation of the Regulations give undoubted power to the Superintendent-General and to her Matrons on foreign stations, I should prefer having no bond. But this is for a man of business to answer. It is important to remember that the power of instant dismissal for misconduct, and of sending the Nurse home must be retained, which renders the service different from ordinary female service. A discharged governess or servant, if she insisted on remaining at her own expense at the foreign station, could not be sent home forcibly by her late mistress; now it is essential that an offending Nurse be forthwith passed on board the first returning ship. Also performances similar to those of one or two of the women in the War-Hospitals who, on hearing of good situations, misbehaved in order to be discharged, ought to be effectually prevented. A lawyer must advise, first, if it can be; secondly, how it can be done. The Superintendent-General, on sending abroad Nurses, ought to have some security either that they remain there and do their duty, or that they be sent home for her judgment if they fail in duty. To have them either going abroad as Nurses by way of securing a free passage, and then looking out for lucrative situations, or accepting the offers which might, and, occasionally, undoubtedly would, be made to them, would be most injurious to the Service. Can it be prevented by any stronger measure than the instant forfeiture of all claim to the eventual pension? If so, it should. Could this power be extended to the washerwomen who would probably be sent with the Nurses ordered to War or out-of-the-way foreign stations? Perhaps it will simplify things not to include them in the Regulations.

Hospital Laundries.

The persons provided by the Officer, whoever he may be, to attend to the hospital linen under the orders of the Matron, will be pretty sure to give the Matron trouble. But it is much better to begin very modestly, and to avoid alarming the Attendance Department; and so to be content with the people provided in the linen store, and not at all to invade the regions of the kitchen. By degrees, please God the work prospers, it may be extended. I fear a laundry of men, except in war-service, will be a costly and inefficient concern. Yet a laundry of women, exempt from the control of the Matron, would be probably the worse evil of the two. And it is both right and expedient to move very slowly, and to begin with the nursing service alone. Ultimately, if we invade both laundry and kitchen, I should still wish, in both, to have as few women as possible. The fewer women are about an Army Hospital the better.