Of the hundred thousand needless deaths which take place annually in our country how many are occasioned by bad or deficient nursing? More by thousands than would be supposed by persons who have not attended particularly to the subject. But the most hasty view will show that the number may be very great.
What is the popular notion of a nurse? And how docs it correspond with the haunting conception of 100,000 people yearly dying who have a claim upon us to live? Let us try to imagine that doomed multitude — the ten thousand carried off by small-pox — the little children strangling in croup by scores — the hundreds sinking delirious in hospital erysipelas — the wards full of hospital gangrene — the tens of thousands swept away by fever and cholera, as by a whirlwind. Let us steadily contemplate such a scene as this, and then call to mind all we know about nurses, and consider the proportion which the two classes of sick and nurses seem to bear to each other.
How much good nursing have any of us ever seen? At the mention of good nursing, the heart may spring to the touch of some precious remembrance of exemplary nursing in a quiet home, where nothing was said about it, because it seemed to be a matter of course. Wherever there are mothers and daughters and sisters, there will be more or less good nursing, as far as it can be taught by good sense and affection, in the common maladies which befall individuals.
But nursing is an art based upon science: and the resources of instinct, which are often insufficient in individual cases, are as nothing in the conflict with epidemic sickness, or when accidents and unusual diseases occur, or where numbers are down at once. Such a mortality as our Registrar’s returns show can be contended with only by a great body of trained nurses, whose vocation shall be recognised and respected by society.
To be, to do, and to talk “like an old nurse,” means to be positive, ignorant, superstitious, wrong-headed, meddlesome, gross, and disagreeable, and to speak and act accordingly. The expression arose out of the deficiency of nurses, by which the occupation was delivered over to women who could do nothing else, or who relished the power and luxury enjoyed by the monthly nurse in comfortable houses.
The monthly nurse was employed in sick-nursing too, no doubt: but the monthly engagement was tho inducement, and that class of women were wilful, ignorant, and luxurious in proportion to their importance and their scarcity. We will not spend our space on the familiar story of the tricks and foibles and disgusting selfishness of the traditionary nurse. The image may be found in a multitude of works of fiction, and the reality in most elderly people’s recollections of their early life. Let her retire behind the curtain to doze and booze and maunder out her queer notions about diseases and remedies. We have to study newer specimens of the same order of functionaries.
In every town, great or small, we know some widow or spinster who gets her living by nursing among the cottagers or small shopkeepers and artisans. She knows how to manage lying-in cases, in a general way, and she is a good creature in all cases. She is kind when called in the night, and she is willing and ready to sweep the room, and wash the patient, and make the cup of tea or gruel.
The greater part of the nursing which is done by hire is done by this sort of woman: and she is immeasurably better than nobody; but she knows nothing of the structure of the human body and its various organs and their uses; she is not enlightened about the importance of air, light, or temperature; she has wild notions about food and medicines and infection and the character of diseases; and it is a great thing if she is able to dress blisters or apply leeches or fomentations skilfully.
Formerly it was very difficult to find anybody of a higher quality than this when a hired nurse was wanted in a family; and even now, the grand perplexity of physicians is to answer the demands upon them to supply well qualified nurses in any proportion to the patients who require them.
The census returns of 1851 throw some light upon the facts of the proportion of nurses to the sick. Domestic nurses (meaning nursemaids) are a separate class, though the chief part of the tending of children in sickness is done by them. They amount to nearly 40,000, of whom, strange to say, almost half are between five and twenty years of age. We find under this head the little nurse-girl, who may be met in a town alley, sitting on a door-step, rocking a baby to sleep, or carrying it bent double on her arm, while her own shoulder is growing out, or her spine getting twisted with carrying a heavy weight before she has done growing.
Convulsions, croup, accidents kill a multitude of infants in such hands, who might live to die of old age if there was anybody to show how to ward off or treat such misfortunes. But, though the attendants of children are called nurse-maids, the last thing that they are taught is anything about nursing.
Going on, then, to the class which claims the title, in virtue of actually professing to nurse, we find that in Great Britain there arc, including monthly nurses, above 25,000 women who take charge of the sick professionally. In comparison with the deaths, and infinitely more with the sickness in tho kingdom, this number is almost incredibly small. It would seem a mere nothing if we did not remember that a large proportion of them are hospital nurses — each one taking charge of many patients.
In fifteen London hospitals there were, last year, 521 nurses of every class. Every large town in the provinces probably has its infirmary or hospital, with a staff of nurses. It has been proposed to fix twenty-five patients as the proper number to be attended to by a single nurse; and this may serve as some sort of a guide in contemplating the extent of the need of more nurses; but we are told by experienced persona that no such rule can be enforced, nor ever could be, if hospitals were much better organised than they have hitherto been. In military hospitals, for instance, in time of peace, the patients are, on an average, very slightly ill in comparison with the inmates of a civil hospital; and it may be easier to attend upon fifty of tho regimental patients than five-and-twenty in a city or county infirmary.
There must be endless varieties, too, in the fatigue of the office according to the management of the institution. For instance, in one there may be such arrangements as that the nurses are at liberty to spend their whole time among the beds of their patients, while elsewhere the nurse is expected to carry up coals and water, and carry down trays, and fetch and carry and even wash the linen, and go for the medicine, and cook the diets. Supposing, however, that every hospital was well managed, there would still be a sad deficiency of desirable nurses: and when the number of sick throughout the kingdom are considered, the paucity of qualified attendants is really terrible.
The thought, is not new. For half a century at least it has been a subject of speculation, through the press, in lectures, and in conversation, why the deficiency remains so great, and how to supply it. Considering the vast number of Englishwomen who have to work for their bread, and the over-stocking of many departments of female industry, it seems surprising that this, which is so especially women’s work, should be done so scantily and so badly.
As sanitary inquiries have been pursued further and further, it has been discovered more and more plainly that a vast amount of needless death happens from bad nursing. We are told that in order to reduce the preventible mortality we must (among other things) improve our hospitals; and, in order to improve our hospitals, we must improve our nurses. While many of them are diseased and infirm; while more are intemperate, and not a few loose in conduct and character; and while they are under overwhelming temptations to make a profit of their patients and their place, there can be no effectual check to the needless mortality within the hospitals.
One result of such discoveries has been to create the enthusiasm which we have witnessed of late years in the cause of good nursing. Florence Nightingale did not wait for the outburst of an enthusiasm on any hand. For many long years she had been working in silence, under a growing sense of the necessity. She had been learning the art, and putting her knowledge in practice as she advanced, so that when, under the pressure of the war, there was a sudden rush of devotees into the vocation, there was a woman ready to guide the movement, and to lay open the case to the steady good sense of society, precisely when good sense was most in danger of being swamped by the mixture of a romantic egotism with a gush of genuine benevolence. Through her we know something of what it really is to nurse the sick, and of what is wanted to plant good nursing effectually between the sick-bed and the grave.
There is no subject on which it is easier to be romantic than that of nursing. It is natural and fitting that the tender and even picturesque aspect of the office should fix the attention of observers: only, when it comes to reforming the institution, the whole truth must be studied. It is pretty to see a little child nursing poor mamma’s foot when poor mamma’s head aches; and one feels a respect for young ladies who aspire to undertake the work of a Sister of Charity: but the little child’s nursing, though it need not be discouraged, will not cure mamma: and the well intentioned assistant must go through a severe probation before she may venture to regard herself as a Sister of Charity.
The imaginative benevolence and piety which may find their proper training and final use in some other department of action, are usually out of place in tho hospital; and it really appears that there is as much trouble with floating saints and virgins on the one hand, as with grovelling mercenaries on the other.
As for the minority of able and devoted women who stand between or far above them, they are of a value which can scarcely be matched among women. If we look at them, we shall no more see them gliding about in silk, or floating in muslin, or disguised in a hideous nun’s uniform, and lecturing their patients on heavenly things by the hour together, or exchanging spiritual confidences with fevered sufferers, than we shall see them drinking gin behind a bed-curtain, or taking a bribe from a visitor. Some documents are lying before me, which show what we shall find the best nurses really doing. To observe them in their proper sphere, we must imagine the best managed hospital that we can ever hope to see.
It is not every woman who desires it, or is worthy of it, that can be a professional nurse. She must have a degree of bodily soundness and vigour which is not common; for her work is not only very hard, but it keeps her standing and stooping for many hours of every day. The successful nurse must have ascertained, before she declares herself a candidate, that she can stand and stoop to the required extent without injury. She must have stout limbs and sharp senses. We know well enough what it is to have a nurse who is purblind, or hard of hearing, or insensible to bad tastes and smells.
Next, what is to be the relative position of the candidate? Is she to be mistress or servant, does she suppose? “Servant, of course,” she replies. Very true: but has she considered what it is to be a servant in so strict a sense as in a hospital? She must have no ideas and no will of her own about medical treatment. Instant, constant, complete, silent obedience to the physician’s orders is her very first duty. Does she suppose this to be at all times easy? Whether entitled by a special education, or prepossessed by ignorance, she can hardly help having notions about the cases under her hands; and it must be difficult at times to yield to a questionable order without a word spoken. Yet there can be no freedom to question an order in a hospital, though there might be an opening for discussion in a private house.
Again: there is no choice of hours, or of work, or of methods. All is fixed and settled; and she has only to put herself under the working of the machinery of her office. Every day has its routine — every hour its proper work: what change and recreation can be allowed are out of the house: there can be no controversy, religious or other, with colleagues; and there must be no petting of patients. This is with some the hardest piece of self-denial of all: but duty requires it. The aim is to get the patients well. That is what a hospital is for.
In the vast majority of cases of illness, a vegetative mode of life, monotonous, material, calm and quiet, is as essential as it is to the youngest infant; and this is the reason why physicians dread, as they do, the introduction of sentiment and sentimental women into hospitals. The religious care of the patients belongs to the chaplain, or the pastors, who may visit patients from their flock: and, women once admitted to any other functions than ministering, under orders, to the bodily needs of the sufferers, there would soon be an end to the expansion of the profession at all, and to all chance of women having the special hospital education which it is the great aim at present to obtain for them.
It does not follow that the nurse must be mute, hard, and unsympathising. True sympathy shows itself otherwise than by talk and tears. Whatever is done may be done gently and tenderly. Mere vigilance, without words, is often the most acceptable form of sympathy to a sufferer; and two words of pity, or of cheerfulness, or uttered in the spirit of fortitude, may rouse or charm more than any exhortation.
The nurse has to see a constant succession of patients going out and coming in, so that the scene might well weary out the most elastic imagination and the most patient heart. I have said nothing of the spectacle of ghastly wounds and sores, of the long waiting upon fever, of the moans and cries of anguish, and the dreary weeping of the worn-out sufferers. It is to be assumed that the nurse has ascertained that she can bear these sights and sounds. It is a matter of course that she can; and also that she is free from the prudery which is somewhat in the way of benevolent action wherever it exists, and is wholly incompatible with the nursing office.
Supposing all these conditions to be satisfactorily met, what is the life led by a good nurse?
In the London hospitals there are two classes of female nurses: the Matrons and Sisters constituting the first, and the Nurses (sometimes subdivided into day and night nurses) the other. If ladies choose to enter either class without pay, in any future scheme, there must be no notice taken of the difference; but the unpaid must be subject to precisely the same regulations as the salaried.
Neither money nor religious vocation can be allowed to confer privilege while the object is to obtain the largest possible number of respectable, healthy, sensible women of the working class, in return for a fair maintenance; that is, on the footing which is generally found to be the most steady and workable. At the moment when new sewing machinery is demolishing occupations which had long ceased to afford a maintenance, a new profession is opening to women, through the extension of our sanitary knowledge; I and the system must be adapted to the professional members first. The volunteers and amateurs must take their place under it as they can.
It is found that, as paid nurses, widows with children are ineligible. If they do not love their children they are unfit to be nurses; and, if they do, they must be for ever pulled two ways. The cases of peculation and trickery thus arising are numerous, but not at all to be wondered at. The nurses had better be single women, or widows without children. It is part of the romance of the enterprise with some people to introduce penitents to the wards; but this is reprobated by all experienced managers of hospitals. It is all important to respect the corps of each hospital, and to keep up their self-respect.
There must be no damaged character amongst them, for the sake of the sound. If there is any of the old leaven left, this is the place and the work to bring it out; and if the reform be complete, the penitent must have too much disquietude, self-distrust, and egotism stirring within to be fit for an office singularly requiring robustness and simplicity of nature and habit. Penitents can find works of mercy always wanting to be done in every track trodden by human feet; they need not come to the public hospital, while there are so many private sick chambers; and it must be plainly said that they cannot be admitted.
Our good nurse must then be a single woman, say of the working-class, and about thirty years of age; sound in health, and well disposed for her work — with a calm, cheerful manner, but with a glow within which we should call enthusiasm, while she is not aware that it has, or ought to have, any name. As we are supposing her in a well organised hospital, she is trained for her office.
The time is at hand, the money is in the bank, and the plan is under discussion, for tho training of young women in the art of nursing; so we may look forward to the accomplished fact. She will have learned what the structure of the human frame is, in a general way; where the great organs lie, and how they ought to act. She will have learned how health is affected by food, clothing, cleanliness, exercise, and free ventilation. She will have been taught how to put on a bandage in the various cases required; how to manage leeches and other applications, and how to prepare the commonest sick-diets; and how to act in emergencies — of bleeding, fainting, convulsions, inflammation, choleric attacks, &c., till the doctor comes.
Thus fitted for her work, she enters upon it with the full knowledge that hospital-nurses have to undergo a period of discouragement, during which many feel that they must get out of it at any cost. An experienced reader will know what is meant by the hospital languor which comes over the nurse, after a time, like a sick dream. It is easily accounted for; and the only object in adverting to it, is to point out that it is a common trial which all nurses have to undergo, and which good nurses get over, by spirit and prudence. She does what is possible to secure an easy mind and a disengaged spirit by availing herself of some one of the safe methods of assurance, within or without the hospital, by which a certain deduction from her pay will secure her the means of retiring before she is quite worn out.
She will further make a point of laying by something, so as to have the power of taking a complete holiday, however short, when she needs change of air and rest. There are consultations on foot as to these matters — as to methods of insurance, and of making savings from the wages of nurses, on the one hand, or pensioning them on the other.
The economy must not be too close. A nurse must be well clothed, and thoroughly well fed. If she provides her own food she considers it a duty to sustain her strength by substantial meat dinners, with good beer; and if her meals are provided by the hospital, she steadily demands whatever is necessary to enable her to discharge her fatiguing duties effectually. The hope of those who are consulting about making the most of nurses, is that a plan will become general by which there shall be in every hospital a mess for the nurses, managed by the matron.
The most wasteful of all plans, as to food and time, is for each nurse to buy and cook her own meals, and eat them alone; and it certainly would seem to people generally that sitting down to a joint and pudding would be more cheerful and comfortable than each woman fiddle-faddling at her own bit of dinner. An open, honest, sufficient allowance of good ale or porter is essential if the curse of hospitals — intemperance — is to be successfully dealt with.
The temptations to spirit drinking are stronger than can be conceived by women who sit at home over the easy occupations of ordinary life. On the one hand, the vice is always trying to establish itself; on the other, it is impossible to tolerate it in a hospital; and the thing to be done is to keep watch against it, and to substitute for it generous diet.
Our nurse’s clothing must be ample. There can be no shutting out the air, and keeping up the fire in a hospital, where the principle is to have such bedding, clothing, and equable warmth provided as shall allow of free admission of fresh air at all times. The nurse must therefore be so warmly clothed as not to suffer in winter days, or in night-watches, in going about her ward.
These are her personal arrangements; each of them important as involving her health and strength. As for her business, it is a very regular affair, except in as far as her deep interest in her work may introduce diversities. A high authority exhorts the hospital-matron not to worry if a day nurse is seen sitting up with a bad case when, as the matron would say, she ought to be in bed. As a general thing, however, the nurse should have her eight hours’ sleep, as well as two hours a-day for recreation, and two more for meals and her personal business.
When the true quality and value of a nurse are understood, she will not be employed to do what others can do as well. Therefore our nurse is not to be seen bringing in water, lighting fires, or scrubbing the floor. She sees that everything is ready at first, and then enters upon her duty to the patients. She helps those who cannot wash themselves, and makes all clean and pure from bed to bed. She serves the first doses of medicine for the day, the list of which hangs up where the doctor and she can easily refer to it. To give the medicine punctually and accurately is of course one of her first duties; and she trusts nobody with it. At breakfast time, the meals are brought to the ward, as the dinners are, ready divided and hot, so that her time is not consumed in dividing — much less in weighing — the food.
The arrival of the doctors is prepared for by her being ready to report on each case, and her having ready any questions she may have to ask. She makes her words as few as possible. She has her own slate or book in which to enter orders or questions: and her manner checks the thoughtless students (supposing them present) when they are noisy or obtrusive, to the discomfort of the patients. By the time the medical rounds are over, and the offices ordered by the doctors arc fulfilled, it is time to prepare for dinner. She encourages those who are well enough to rise, and sit at table; and she tries to make a cheerful fireside for as many as can sit up during the afternoon. She altogether prohibits any such illicit indulgence as a pipe in a closet, or pastry or drink brought by visitors; while she encourages cheerful amusement in every way. She has the beds made, the linen changed, the night-lights in order, and everything quiet by the prescribed hour, when she yields her place to the night nurse.
All this may be easy and almost pleasant to the reader; but it is the mere framework of hospital life. The filling-in is the part to study. Among twenty, thirty, or more sufferers, there is no day which can pass over smoothly and without anxiety. The child that cries aloud for half the day would wear out many a woman’s nerves: and then there is the moaning of people in pain, and the restlessness of the feverish, and the raving of the delirious. There are wounds and sores to be attended to; and many disagreeable things to be done; and usually, among so many patients, some on any particular day who seem not to be doing well. The toil is never-ceasing; the anxiety always besetting; the wear and tear in every way very great.
On the other hand, good nursing decides the fate of thousands of persons every year, for recovery or death. In badly managed hospitals there are epidemic periods when erysipelas, hospital-gangrene, cholera, and fever carry off the patients just as if they were living in a blind alley full of bad smells and stagnant filth; but, as a general rule, people who go into hospitals come out convalescent: and if the arts of the hospital were spread over private life, the number of deaths from other causes than old age and vice would be wonderfully reduced.
A well-trained body of ten thousand nurses, working during only their years of utmost vigour, would do more to extinguish preventible death than the twenty thousand haphazard town and country nurses, old and young, set down as professional in the census returns. What the actual need is may be judged of by the existence of the Nightingale Fund; by the number of ladies who volunteered to go to the East during the Russian war; by the institutions which are springing up in various parts of the country; and by the tentative conversation of young ladies who meditate devoting themselves to the work. How to meet the need, is the question.
It must always be right to develop all existing capabilities in private life. In every household let little children show what they are made of. One will mount a chair, and stare into your mouth to see a tooth drawn, while another will run out of the house when the dentist comes in. One will faint at the sight of blood, while another likes to bind up a bad cut. Why should not the natural doctor and nurse have a free career? There will always be plenty to run away from it. Let little children be allowed and encouraged to soothe and help the sick. Let them learn to sit quiet, to move about quietly, to stir the fire with a stick, to chafe limbs properly, to make a bed properly, and change linen in the easiest way; to air rooms, to darken windows, and to make and serve sick messes. These things can be learned and practised at an early age; and the process will certainly show what Nature intends as to a supply of nurses.
The material thus indicated, what is the instruction to be? At Madras, the orphan daughters of British soldiers are educated at the Military Asylum, where the elder ones who show themselves fit for the service are trained as nurses, and always diligently sought. Married or single, they are always busy. As their fathers battled in the field of warfare, so do they in that of disease ; and they are the most effective soldiers in the world. Not only in India, but everywhere, does disease lay low its victims more painfully and more plentifully than any war that ever was waged.
We cannot help sending out our armies occasionally to slaughter and be slaughtered; but we might more than compensate for the mortality of war if we would send out that other redeeming force which contends in the field of disease, and rescues its captives from the threshold of the prison-house! When a nurse died in the East there was great mourning; and it was openly said that the best soldier could have been better spared — the object . then being to save soldiers. A good soldier’s j place may be filled, though at great waste of I safety, of feeling, of convenience, and of money; I but the place of a good nurse cannot be filled at! all. Every existing one is excessively wanted, and cannot be spared from her post.
There are women enough in England — working women enough — devoted women enough, if the training and the encouragement were provided. It is not the fatigue, nor the disagreeableness, nor the anxiety, nor the low and doubtful position of nurses, which keeps us so bare of them while other departments of female industry overflow. It is that no woman who would be a nurse knows where to go and what to do to qualify herself.
Open schools to women, and provide a new department in children’s schools, and the sick of the next generation will not die by tens of thousands for want of good nursing. Disease will be checked on its first approach, and the mortality of our day will be a theme which will take its place in history and speculation with the Great Plague and the Black Death. The doctors permitting and aiding, the women will achieve this victory.