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who enter as lady probationers may be roughly grouped in two divisions :
1. Those ladies who take up nursing from religious motives.
2. From preference for the work, and with the view of earning a livelihood.
There are those who undertake nursing for a time from more or less personal motives, but we need not concern ourselves with them here.
The two classes we have mentioned are practically united in aim, and are the backbone upon which hospital committees have mainly to rely for the superintendents of nursing. It often happens, however, that a severe conscientiousness prevents members of the first class from ever doing the full amount of efficient work for which they are specially fitted. To give one example out of many known to the writer. A lady by birth and education, who had to earn her own living, chose nursing by preference, and on religious grounds as the means to that end. She was thoroughly trained, and became one of the most competent nurses in the country. Capable as an administrator, conciliatory in manner, tender as a nurse, and possessing the power of winning the affections of her patients and of the nurses under her, she never became the head of a large institution. Why? Because she was so punctiliously conscientious, that is to say, she stood always in her own light. She was ever troubled about trifles. Thus, when she was selected as one of two for a post of responsibility, she invariably appeared in garments resembling those of a religious order, although she held herself aloof from all such organisations. When remonstrated with by her friends, she would claim the right of independent judgment, and declare that as long as she was a nurse, she would wear a distinctive uniform. If asked by one of the electing body if she was a member of a sisterhood, she would resent such inquiries, and would by her manner excite a prejudice against her. If a cause was unpopular, and should any of her friends be associated with it, she would often join them, especially if there had been any little disagreement between them recently. Her reason for this course was that it humbled her, and if she brought discredit upon herself thereby, she held that she deserved to suffer for her former fault. Actuated by the highest principles she lacked common sense, and when eventually appointed lady superintendent of nursing to a large hospital, her conscientious discharge of duty rendered her administration a failure, because her zeal was not tempered hy discretion. There are many such characters in the nursing world. It is to be regretted that so inuch
. that is admirable should be rendered absolutely useless because religious enthusiasm seems in such cases to remove all adequate appreciation of the necessarily practical character of our dealings with others.
The second class stands out by itself. It includes the majority of lady probationers, and it is being rapidly recruited as to numbers
each year. Nevertheless, it must be remembered that as one swallow does not make a summer, so a year, two, nay, five years' training in nursing will not necessarily produce a competent matron or lady superintendent. To the qualities of a skilled nurse several other most important qualifications must be added. To wit, a knowledge of the world and of character, the power to organise without friction but with efficiency, firmness, tact, discretion, and unselfish adherence to duty. All these and many more qualities will be necessary before a lady can hope to be a success in such an office. It is not surprising that it is found more difficult in practice in the present day to secure the services of a really competent woman for the head of the nursing department than to introduce a new and efficient system of nursing. It follows likewise that where efficient nursing has found a home, it has often only remained efficient so long as a competent lady has been in charge of the department. Change your superintendent, and no matter how efficient the system, it will become a dead letter in twelve months unless the new comer is up to her work. The field is a large one, the remuneration is fairly liberal, but the labourers are at present few. Some four hundred posts, varying in value from 351. to 150l. per annum, exclusive of board, residence, &c., are now open in the United Kingdom in connection with the medical charities alone. Yet so few, comparatively speaking, are the candidates available, that there is little, if any, choice. Everyone regrets the fact, and no one who has a knowledge of such matters fails to recognise that the absence of competent gentlewomen for such posts is much to be regretted. Knowing this, all who are actively engaged in the practical details of hospital administration have read Miss Lonsdale's article with pain, because she has (unwittingly no doubt, but none the less certainly) lessened the chances of a sufficient supply of competent ladies for these posts in the future. The chief of the nursing department of a hospital has great responsibility, her duties are onerous, and her competency is a necessity if the new system is to be successful anywhere. For these reasons, her position, prospects, and training form probably the most important factor in successful hospital nursing in the present day.
Lastly, what position do the nurses occupy in the new system? Necessarily an important one. Without their aid, and unless they are efficient, good hospital nursing must be conspicuous by its absence. At the outset, the writer's preference for a common-sense system of nursing, in preference to a sisterhood or other outside organisation, was declared. His experience convinces him that any institution can, to say the least, secure as good a system of nursing within its walls, by placing the department under the direction of a competent lady selected by the committee, as it can by calling in the aid of an outside authority, which, like all outsiders, will not only cost a great deal of money, but will also demand large privileges. A nursing sisterhood or training school is too apt to use the hospital wards as a means to the particular end of such bodies—private nursing. The
writer recognises and is fully conscious of the great good which the sisterhood of St. John's House, for example, has effected. To it we owe much improvement in the comfort, the circumstances, and the position of matrons and nurses alike. By its wise selection of competent ladies many hospital committees have been placed under great obligations. But when all has been fully allowed that can be allowed in favour of sisterhoods of this character, it cannot be doubted that the result attained is scarcely adequate when the cost is considered. An imperium in imperio is never a system to commend itself to the judgment of a wise administrator, and the unhappy conflicts which have been waged in the past justify the most prudent of hospital managers in their preference for other methods of attaining the desired result. Thus the Nightingale or common-sense system has great advantages. Given a competent matron, who understands her work, it places such a woman under proper control, and leaves her within reasonable limits and after consultation with the medical staff to effect the needful changes in the nursing department. This plan is sure to work well. To quote an instance. At the Royal Infirmary, Edinburgh, under the able guidance of the General-Superintendent, Mr. F. C. Fasson, such a system has revolutionised the whole nursing department, to the great credit of everyone concerned, without any disturbance or conflict of authority. Years ago Miss Jones, of Liverpool, built up a model school of English nursing on this system with success. At Winchester, at York, at Norwich, at the Queen's Hospital, Birmingham, and at many other places, the common-sense system has done wonders in a short time, and without causing bickerings or discomfort. The method adopted is almost everywhere the same. It is assumed at the outset that a nurse will attach herself to the school at which she is trained. Like a student at college, there is none in her estimation to equal, much less to rival, that at which she was trained. The system, the training, the arrangements, leave little, in her opinion, to be desired. Hence a constant supply of competent nurses is always available at the institutions where the common-sense system is at work. It is known to the more experienced hospital managers that a nurse who is really good all round will not be allowed to leave the hospital where she was trained for the sake of a few pounds a year in wages. Hence it usually happens that, when a trained nurse is advertised for, the applicants for such a post if really 'trained' in the right sense of the word, have been allowed to leave their alma mater because they possess some special vice. It may be temper, untruthfulness, flightiness, disobedience to orders, want of application, insobriety, or some other failing which has proved too much for the patience of the authorities at her first school. Whether it be one or several of these traits of character, experience proves that they are sure to be present. Hence, to advertise for a trained nurse is almost to tempt providence, as it often leads to the introduction of an element into the hospital world which had better have been left outside. Unless a hospital
trains its own staff of nurses, this part of its administrative work must always be in an unsatisfactory state. Those who question this assertion can have had little practical experience in hospital management.
The following history of one year's work at an institution having an average of between 150 and 200 occupied beds will prove instructive and interesting. During twelve months ending April 30, 1880, 121 respectable young women-farmers' and tradesmen's daughters, milliners, upper servants, and others—applied to be taken on as probationer nurses. These young women came from all parts of the country, from the counties of Cornwall, York, Lancaster, Warwick, Norfolk, Sussex, Northumberland, Hampshire, and Kent, and many other places. It may therefore be concluded that they fairly represent the average type of the classes to which they belong. The results are not encouraging, but they will show the public that, although very many young women think themselves capable of becoming good nurses, very few can stand the preliminary test of one year's probation. Of the whole 121, 50 applicants were not written to, as they appeared on the surface to be unsuitable for the work. Of 71 to whom forms were sent, 58 did not continue their application, as they found the work too hard or to offer insufficient attractions to induce them to undertake it. Two others were rejected by the authorities as too young, and one proved unsuitable before entering on her duties. Of the whole number but ten remain to be accounted for. Of these but four have turned out really competent nurses. Of the remaining six, two broke down in health after a few months' trial, two left to be married, one had no capacity for the work, and the last, a young farmer's daughter, aged twenty-four, was found to be a confirmed drunkard. It will be seen from the above figures, that out of the whole number of applicants less than 3 per cent. proved efficient, and of those who were retained for twelve months only 40 per cent. stood the test.
The authorities of the Nightingale Fund find that about 60 per cent. of their probationers ultimately continue as trained nurses. The reason is not far to seek. Nursing is an arduous, a responsible, and a trying occupation. The confinement, the anxiety, and the disagreeables prove too much for the feelings, the health, and the patience of a great number of young women. Although a good income, a reasonable amount of independence, the prospect of a pension after long service, and fair chances of promotion are offered as inducements to remain, unless a woman really takes kindly to nursing all these will prove insufficient to retain her services. Anyone who considers the question fairly will at once perceive that hospital managers have great difficulties to overcome. For this reason, when once they have successfully trained a good nurse, as we have before said, they will take great pains to keep her in their service. Hence the trained nurses' who offer themselves for engagement are not usually in all respects desirable, and so some of the
nurses from the so-called Nurses' Homes, which are sent into private families, prove anything but satisfactory.
Of course, a hospital committee can avoid all the trouble incidental to training a number of nurses for their work by contracting with an association or a sisterhood to supply what they require. This method, however, costs at least a third more, and it necessitates——if King's College Hospital may be taken as a fair sample of the system—that the medical staff, and for that matter the managers generally, shall allow the nursing to be put first in everything. Briefly, it means first the nursing, and then what you please, but nothing must interfere with the nurses or their superiors. Few hospitals will submit to such a system. Under it, the students and the resident medical officers suffer many injustices. The failings of previous holders of the resident appointments form a sort of accumulated list of vagaries, which the lady superior considers it her duty to guard against. In the case of a new comer he is warned that he must not commit any one of these offences; and as each little failing is carefully noted, the list soon assumes alarming proportions. On the other hand, the sisterhoods really nurse their patients most efficiently. The number of nurses, the system of training, and the class of women engaged all commend the system to imitation and approval. Its great fault is that it arrogates to itself an authority which it is not entitled to possess, and which it is desirable the nursing department should never assume in English hospitals. It further necessitates frequent changes in the personnel of the staff of each ward, a method of nursing which is fatal to the comfort of the patients and the medical staff. It, however, enables the lady superior to show her authority and to exercise it at pleasure, and so this last regulation forms a prominent feature in the nursing system of all sisterhoods. If any hospital managers desire to appreciate fully the evils of nursing sisterhoods, and the dangers of allowing them to take too prominent a place in the English system of hospital administration, let them visit the French hospitals, and make inquiries there. Anything more unsatisfactory can scarcely be conceived, and the cost is too great to render a general extension of the system probable or desirable.
In saying this much the writer wishes to declare his conviction that all systems should find a home on English soil. He rejoices that St. John's House, for instance, is prosperous and in vigorous health. It has done much for English nursing, and the opportunities it possesses, of showing what a sisterhood can do, are most desirable and satisfactory. It is efficient and expensive as a system of nursing, and its drawbacks have already been referred to. These drawbacks render a universal adoption of this system impossible ; and the writer, whilst recognising fully its many merits, rejoices in the knowledge that this is necessarily the case.
On the other hand, the common-sense system, which Miss Nightingale recommended and instituted, is the one best adapted to