Nursing

Nursing. The development of sick-nursing, which has brought into existence a large, highly-skilled, and organised profession, is one of the most notable features of modern social life. The evolution of the sick-nurse is mainly due to three very diverse influences - religion, war and science - to name them in chronological order. It was religion which first induced ladies, in the earlier centuries of Christianity, to take up the care of the sick as a charitable duty. The earliest forerunner of the great sisterhood of nurses of whom we have any record was Fabiola, a patrician Roman lady, who in A.D. 380 founded a hospital in Rome with a convalescent home attached, and devoted herself and her fortune to the care of the sick poor. She had a rival in the empress Flaccilla, the pious consort of Theodosius I. (A.D. 379-395), who also personally visited the hospitals and attended on the sick. Organized nursing does not appear to have formed any part of medical treatment, except in so far as the deacons of the church attended on the poor, until the 4th century of the Christian era. After that date the employment of women for this purpose must have developed rapidly, for in the reign of Honorius (A.D. 395-423) six hundred women were engaged in the hospitals of Alexandria. These institutions were managed by the clergy, and throughout the dark and middle ages the hospital and nursing systems were connected with religious bodies. Nurses were provided by the male and female monastic orders, an arrangement which still continues in most Roman Catholic countries, though it is gradually being abandoned through the increasing demands of medical science, which have led the hospitals to establish training schools of their own. The names of the oldest foundations which still survive, such as the Hotel Dieu in Paris, St Thomas's and St Bartholomew's in London, the order of St Augustine, and (in the form of a modern revival) that of St John of Jerusalem, sufficiently indicate the original religious connexion. The order of St Vincent de Paul, founded in 1633 for the express purpose, is still the largest nursing organization in the world. Even in Protestant England, where purely secular training schools have reached their highest development, the generic title of Sister, alike prized by its holders and honoured by the public, remains the popular and professional synonym for head nurse, and perpetuates the old association. Nursing, as a popular or fashionable occupation, is not a modern invention. Sir Henry Burdett quotes an order, dated 30th May 1578, directing the master and the prior of the Hotel Dieu "not to receive henceforth any novices without speaking of it to the company, because there are an excessive number of nuns and novices, who cause great expense to the said Hotel Dieu." In Protestant countries a secular nursing system came in with the Reformation. The staff appointed for St Bartholomew's, on its re-establishment by Henry VIII. in 1544, consisted of a matron and twelve nurses, who were engaged in domestic occupations when off duty. Thus nursing became a menial office and an inferior means of livelihood, adopted by women of the lower orders without any training or special skill; and so it continued down to the middle of the 19th century, when a new movement began which was destined to revolutionize the status of the nurse.

Its distinctive feature was the systematic training of nurses for their vocation. Previously a certain amount of regular instruction had no doubt been given here and there by individual physicians and surgeons; lectures to nurses were delivered in the New York Hospital as early as 1790. But these were isolated efforts. Such skill as nurses possessed was picked up in the wards. No qualifications were required, nor indeed would they have been forthcoming, so low had the calling sunk in public estimation. The credit of inaugurating the new order of things belongs to Germany, and here again the religious influence came into play. The beginning of the modern system dates from the foundation of the institute for training deaconesses at Kaiserswerth by Pastor Fliedner in 1836. It is true that state training schools for male nurses had previously existed in Prussia, the oldest having been founded at Magdeburg in 1799; but the employment of men in hospital wards is a feature of the German system which has not been copied by other advanced countries, and seems to be in process of abandonment in Germany. It is a heritage from the middle ages, when the Knights Hospitallers undertook for men the duties discharged in female institutions by the nuns. The male schools, therefore, stand somewhat apart, though they mark a stage in the evolution of nursing as the earliest regular training establishments. The Kaiserswerth Institute, on the contrary, had a far-reaching and lasting influence, and may fairly claim to be the mother of the modern system. England, in particular, owes much to it, for there Florence Nightingale acquired the practical knowledge which enabled her afterwards to turn her remarkable gift of organization to such brilliant account. The example of Kaiserswerth was soon followed, and not in Germany only. In 1838 the Society of Friends founded a nursing organization in Philadelphia, and in 1840 Mrs Fry, a member of the same community, started the Institution of Nursing Sisters in London. In 1857 the nurses attached to it numbered ninety. They received their practical training at Guy's and St Thomas's Hospitals. On the continent institutes for nursing deaconesses were founded at Strassburg, Utrecht, Berlin, Breslau, Konigsberg and Carlsruhe between 1842 and 1851. In London a Church of England training institution (St John's House) was opened in 1848. There were three classes - (1) sisters, (2) probationers, (3) nurses. The nursing at King's College Hospital was for many years undertaken by this society, whose members were trained at the hospital.

The training system, thus inaugurated on a semi-religious basis, received a new impetus from the Crimean War, which was further emphasized by the Civil War in America and the subsequent great conflicts on the continent. The despatch of Florence Nightingale with a staff of trained nurses, to superintend the administration of the military hospitals was the direct result of the publicity given to the details of the Crimean War by The Times, and it formed a new departure which riveted the eyes of the civilized world. The work undertaken and accomplished by this lady was far more important than the mere nursing of sick and wounded soldiers. She had grasped the principles of hygiene, which were then beginning to be understood, and she applied them to the reform of the hospital administration. In civil life it had a marked effect in stimulating the training movement and raising the status of the nurse; but substantial results were only obtained by degrees. It was not until 1860 that the modern hospital school system was definitely inaugurated by the opening of the Nightingale Fund School at St Thomas's Hospital, founded with the money subscribed by the British public in recognition of Miss Nightingale's national services, and worked on principles laid down by her. In the meantime several nursing societies, in addition to those previously mentioned, had been founded in England, and elsewhere. Among them the Baden Ladies' Society, founded in 1859 by the Grand Duchess Luise, deserves mention. In the same year the first district nurse began work in Liverpool; and in 1865 the reform of the much-neglected workhouse nursing was inaugurated by Miss Agnes Jones and twelve nurses from St Thomas's, who took up the work in Liverpool. At this time England took a decided lead, which she has never lost. Other countries gradually followed. In Germany the Albert Nursing Society was founded by Queen Carola of Saxony, and the Alice Society by the Grand Duchess Alice of Hesse, both in 1867. In France, where the nursing was comparatively well performed by the religious orders, no change was made until 1877, when a training school was opened in Paris by the municipality, and two others by the Assistance Publique, in connexion with the Salpetriere and Bicetre Hospitals. In the United States schools were opened in New York, New Haven and Boston in 1873. The British colonies, Austria, and other European countries followed some years later.

It remained for the third influence to complete the work begun and to develop systematic nursing to its present dimensions. Since 1880 the increasing demands of medical knowledge have well-nigh revolutionized the craft in the home, the hospital and the workhouse. A large part of the change may be summed up in the words "scientific cleanliness." The outcome has been to raise the dignity of the calling, to induce persons of a superior class to adopt it in increasing numbers, to enlarge the demand for their services, and to multiply the means of educating them.

Nursing does not appear to be regulated by law in any country, though attempts in this direction had been made in England.' Its organization is voluntary, and even in state or municipal institutions is dependent on the direction of the administration. In Great Britain nearly all the general and special hospitals and many of the poor-law infirmaries offer systematic professional training to nurses. The provisions differ considerably in detail, but in the larger schools the system is uniform in all important respects. Candidates must be between 23 (sometimes 21 or 22) and 35 years of age, and must produce satisfactory evidence of character, education, health and physique; after a personal interview and one, two or three months' trial they are admitted for three years' training. During this period they receive regular instruction in theoretical and practical knowledge, and have to pass periodical examinations. At the end of it they are granted certificates and may serve as staff nurses. They pay no premium, and generally receive a salary of P8 to £ 12 in the first year, rising annually to X30 or £35 as staff nurse, and subsequently to x;40 or £50 as sister or head nurse. They live in a home attached to the institution, under a matron, and in the most modern establishments each nurse has a separate bedroom, with common dining and recreation rooms. Private nursing staffs are attached to several of the hospitals; they are recruited from the staff nurses and probationers on completion of their course, and supply nurses to private patients. In the special 1 In 1902 an act was passed to establish a Central Midwives Board and regulated the training and employment of midwives.

hospitals the training is shorter, being for one or two years. There seems to be a constant tendency to increase the requirements. At St Bartholomew's, St George's, the London Hospital, St Thomas's and others, probationers must enter for four years, and at St Bartholomew's they have to pass an entrance examination in elementary anatomy, physiology and other subjects. At all the more important schools the number of applications is many times greater than the vacancies.

In Great Britain trained and certificated nurses generally belong to a society or association. The most noteworthy of the associations is Queen Victoria's Jubilee Institute for Nurses. It was founded in 1887 with the object of providing skilled nursing for the sick poor in their own homes. A great many of the provincial nursing associations are affiliated to it. The number of nurses supported by each branch varies. The qualifications for a Queen's nurse are as follows: (r) training at an approved general hospital or infirmary for two years; (2) approved training in district nursing for not less than six months, including the nursing of mothers and infants after child-birth; (3) nurses in country districts must in addition have had at least three months' approved training in midwifery. Candidates possessing the first qualification are received on trial for one month, after which they complete their six months' training for the second qualification, at the same time entering into an agreement to serve as district nurse for one or two years at the end of the six months. The salary during training is £12,ios., and afterwards £30 to £35 a year, with board, lodging, laundry and uniform. With regard to the earnings of nurses in general, the salaries paid in hospitals have already been mentioned; for private work the scales in force at different institutions vary considerably, according to the other advantages and benefits provided. At some the nurses receive all their own earnings, minus a percentage deducted for the maintenance of the institute; at others they are paid a fixed salary, as a rule from £25 to £30 a year, plus a varying percentage on their earnings or a periodical bonus according to length of service. This is perhaps the commonest system, but some of the best nursing homes give a somewhat higher fixed salary without any percentage. In all these cases the nurses receive in addition board and lodging, laundry and uniform, or an equivalent allowance. For special cases - infectious, massage, mental and maternity - nurses on a fixed salary usually, receive extra pay. The fees commonly charged by high-class institutions for the services of a trained and certificated nurse are - for ordinary cases £2, 2S. a week, for special cases £2, 12S. 6d. or £3, 3s. a week; but many provincial associations supply nurses for £r, is. a week and upwards. The discrepancy between the fees paid by patients and the salaries received by nurses, especially in London, has occasionally excited unfavourable comment, but it is to be remembered that the nurses are maintained when out of work or ill, and have other advantages; many institutions either provide pensions or assist the members of their staff to join the Royal National Pension Fund.

To complete this account of the organization in Great Britain a few details with regard to special nursing are added.

## Fever

Regular training on the same plan as in general hospitals is provided in London at the fever hospitals of the Metropolitan Asylums Board (12 in number, with from 360 to 760 beds each), and at a considerable number of provincial institutions.

## Insanity

The Medico-Psychological Association of Great Britain and Ireland holds examinations and grants certificates in mental nursing; candidates must undergo three years' regular training, with instruction by lectures, &c., which may be obtained in a large number of public asylums by arrangement with the Association; one county asylum (Northampton) gives its own certificates after a three years' course.

## District Nursing

In addition to the Queen's nurses, of whom details have been given above, many local associations train their own nurses for this work. Cottage and village nursing are varieties of the same department; the former is organized on the benefit system, and aims at supplying domestic help and sick-nursing combined in rural districts for an annual subscription of from 2s. to ros., according to the class in life of the family, and a weekly fee of the same amount during attendance.

## Monthly Nursing and Midwifery

Systematic instruction in these subjects is given at some fifty lying-in institutions in different parts of the kingdom. The usual course for nursing is not less than three months, and for midwifery not less than six months; a premium is required of 12 or 13 guineas for three months, and 25 guineas for six months.

## Male Nursing

Two or three associations in London supply male nurses (fees 2 to 4 guineas a week), but there appears to be only one institution, apart from the military and naval services, at which they are systematically trained - namely, the National Hospital for the Paralysed and Epileptic.

Massage is taught regularly at the hospital just named, and at a few other special hospitals. Competent operators are supplied by the Incorporated Society of Trained Masseuses and, to some extent, by other nursing associations; but this branch of the profession is still imperfectly organized (see Massage).

## Children

A large number of children's hospitals throughout the country give regular training in the nursing of children; they take probationers at a somewhat earlier age than the general schools; the course is usually shorter (one or two years), and the salaries slightly lower.

The State offers employment to nurses in the naval and military hospitals. Queen Alexandra's Imperial Nursing Service was organized in 1902. Candidates for it must be between 25 and 35 years, single or widows and of good social status. They must have had three years' training in a general hospital. Foreign Service must be taken as required. Nurses are eligible for a pension after 10 years' service, the amount increasing up to the age of 55 when retirement is compulsory. The Royal Naval Nursing Service is organized on much the same basis. Other organizations are The Army Nursing Reserve and Queen Alexandra's Imperial Military Nursing Reserve, and there is also a nursing reserve attached to the territorial forces.

In the more important British colonies -  Australasia, Canada and South Africa - there are now a considerable number of hospital schools and other institutions formed and conducted on the English model. Salaries and fees are very much the same in Australia; in Canada and South Africa they are higher.

In the United States a similar system prevails in New York, Boston, Brooklyn, Chicago, Baltimore, Philadelphia, New  Haven and many other large towns. The period of training is either two or three years. At the Johns Hopkins School at Baltimore twelve scholarships of $roo and $120 each are awarded annually; graduate nurses are paid $360 (£72) a year. Salaries are altogether much higher in the United States. At the Boston City Hospital graduate nurses receive $ 4 20 (£84) a year, and at the Indianapolis City Hospital those on private duty are paid $72 a month, which is equivalent to £172 a year, with board, lodging, laundry and uniform. This may be taken to indicate the possible earnings of trained nurses working independently, as they usually do in America. The fees charged for trained nurses run from $12 to $25 a week, and even more for special cases. Male nurses are trained at the Bellevue Hospital, New York, the Grace Hospital, Detroit, and elsewhere. In the American schools more attention is paid to the preparation of nurses for private work than in the British (Burdett), and a directory or registry of them is kept in most large towns.

In Germany, their original home, both training schools and societies have multiplied and developed. The period of training appears to be considerably shorter than in Great Britain and America. Members of the Albert Society of Saxony, however, spend two years in the wards at Dresden, and a third at Leipzig, attending lectures and demonstrations. They are sent out to nurse rich and poor alike, and their pay is very small. Most of the German institutes have pension funds.

In France a great deal of the nursing was formerly in the hands of religious orders, but there too the hospital school system, inaugurated in 1877, has grown. The schools managed by the Assistance Publique in Paris give a very thorough course of instruction.

In Russia nursing is mainly in the hands of the Red Cross Society, whose members are, however, trained in the hospital schools.

In Italy, Spain, Portugal and Belgium scientific nursing is in a backward state. The old religious system still prevails to a large extent, and, though some of the orders do their work with great devotion, the standard of knowledge and skill is not up to modern requirements. At San Remo and Rome institutions have been established for providing English trained nurses to private cases.

Austria is also in a very backward state, in spite of the fame of the Vienna cliniques. The Red Cross Society provides a certain amount of trained nursing, and next to it the bestorganized work is done by religious orders; but the nursing in the hospitals appears to be still in a neglected state. The Brothers of Mercy have charge of some of the men's hospitals, and also carry on a remarkable system of district nursing.

In Holland and the Scandinavian countries the organization is more modern and fairly adequate.

For full details on the large subject of the duties and qualifications of nurses the reader is referred to the numerous text-books and other technical authorities. Only a few general observations can be made here. Many candidates qualifica- approach the calling with a very imperfect a reciaPP g Y P PP tion of its exacting character. The work is not easy or to be taken up lightly. It demands physical strength, sound health, scrupulous cleanliness, good temper, self-control, intelligence and a strong sense of duty. It embraces many duties - some of them menial and disagreeable - besides the purely medical and surgical functions. This is especially the case with district nursing, which is the highest and most exacting branchof the profession, because it imposes the greatest responsibility with the fewest resources and demands the most varied qualifications, while affording none of the attractions incidental to hospital work or private nursing among the rich. It is comparatively easy to fulfil routine duties, when every means is at hand and the standing conditions are the most favourable possible; when ventilation, warmth, light and cleanliness are all provided of the best, and when assistance can be summoned in a moment. To be thrown on your own resources and make the best of adverse conditions is an entirely different matter; it requires a thorough knowledge not of routine, but of principles. It is impossible, therefore, for nurses to be over-educated in the fullest sense of the word; but it is possible for them to be inappropriately educated, and perhaps that is sometimes the case now. Probably nursing has been elaborated to the inevitable point of specialization, and a somewhat different preparation is needed for different branches of the art.

Allusion has been made above to the subject of male nursing. It hardly finds a place in the British civil system, and was condemned for hospitals in Germany, where it is at its best, by so eminent an authority as Professor Virchow. In the South African War of1899-1902it was even suggested that female nurses should replace orderlies at the front. The only valid reason for preferring women to attend men rather than members of their own sex is the difficulty of obtaining a supply of equally well qualified and satisfactory male nurses. But this difficulty need not be permanent, and the assumption is much to be deprecated. It is, indeed, most desirable that men should be nursed by men. The advantages are many and real. For one thing women do not possess the physical strength which is often required. They cannot lift a heavy man, and ought not to be asked to do it. Then it is excessively irksome to a sensitive man to be attended by women for various necessary offices. In order to avoid it he will endeavour to do without assistance, and seriously prejudice his chances of recovery.

## Authorities

Sir Henry C. Burdett, Hospitals and Asylums of the World; The Nursing Profession (annual); Hampton, Nursing;  Percy G. Lewis, Nursing, its Theory and Practice; Eva C. E. Luckes, Hospital Sisters and their Duties; Morten, How to become a Nurse;  Florence Nightingale, Notes on Nursing; Nightingale Boyd, "Nursing," in Quain's Dictionary of Medicine.