It is, perhaps, advisable first to speak of some of those difficulties met with in the War Hospitals of the East, in order that such may be prevented for others who may in future be Superintendents-General of Nurses in Military Hospitals whether in peace or in war.
No one ought to undertake a matter of duty of this kind without first obtaining the consent of the War Office to five conditions.
1. That every month, each of her sub-Superintendents shall furnish her with an abstract of the requisitions made by her on the Purveyor, whether for Nurses’ consumption, or for that of Patients, and that she furnish the War Office with an abstract of these. It is then the part of the Purveyor to disprove her accounts, instead of its being, as before, her part to disprove his.
2. That it be made a point of honour, not of grace, with the War Department, to submit to her any Report, confidential[2] or otherwise, made concerning the Female Nursing Staff; a condition, without which it would be impossible to have respectable women in the Military Service.
3. That the powers of the Superintendent-General shall be strictly defined, and put in “General Orders” in the first place, and not in the last, in order that there may not be the useless and endless correspondence which there was in the first Superintendent-General’s case (and for what?).
4. That the Superintendent-General have the power of communicating directly with the War Department; and that her Money-Accounts be sent in by her directly to that Department.
5. That it be made a point of honour that the Medical Officers communicate to the Superintendent-General, or Local Superintendent, any complaint they may have against the Nurses for disobedience.
In March 1856 the following appeared in “General Orders.” Had it but been seventeen months earlier how much it might have saved![3] The definition of the Superintendent-General’s powers and duties, therein contained, is all that is wanted to prevent irregularities disastrous to the Service.
General Orders.
March 1856.
“It is notified, by order of the Secretary of State for War, that Miss Nightingale is recognized by Her Majesty’s Government as the General Superintendent of the Female Nursing Establishment of the Military Hospitals of the Army. No lady, sister, or nurse is to be transmitted from one Hospital to another, or into any Hospital, without previous consultation with her. Her instructions, however, require her to have the approval of the Principal Medical Officer, in her exercise of the responsibility thus vested in her.
“The Principal Medical Officer will communicate with Miss Nightingale upon all subjects connected with the Female Nursing Establishment, and will give his directions through that lady.”
1. Our Nurses were of four sorts.
The Nuns were received not as Nuns, but as Nurses.
Their (so called) training told sometimes against us; sometimes for us. The same with the “Sisters” (Anglican).
The Ladies were useful, exactly in proportion as they approached the professional, and not the dilettante, mode of thought.
A larger proportion of paid Nurses than of Ladies did well, and this under circumstances of peculiar temptation. Paid Nurses are always the most useful.
2. There should always be a proportion of Nurses in Army Hospitals
The proportion of Roman Catholic “Sœurs,” in French Military Hospitals, is as small as this would be; they undertake even less duty than this: in Military Hospitals they do much less than in Civil Hospitals.
Women in Military Hospitals should all be contracted servants, whether Nuns, Ladies, or professional Nurses.
There should be a retiring pension to each woman.
3. Miss Nightingale took service on the ground of being under the Principal Medical Officer, and, consequently, of not interfering with him.
There was no imperium in imperio in her case.
This exists in the case of the French “Sœurs de Charité,” and existed in individual instances among the “Sisters” under Miss Nightingale; i. e., they gave articles of diet, &c., as from Sisters, not in obedience to Medical orders. This was immediately put a stop to by her. That the Medical Officer is sole master of diets, is an axiom of medicine, and of common sense.
This involved our only answering the Extra Diet Rolls in our kitchens; not originating either in quantity or quality.
Afterwards, although frequent were the insinuations that we transgressed the above maxim, no evidence of the fact was ever obtained, except the following, which is given verbatim and literatim, as “put into Court” by a First Class Staff-Surgeon, in charge of one of the divisions of the Barrack Hospital, Scutari. He alleged “that the Nurses were in the habit of giving diets without leave;” and when pressed for the facts, produced the annexed statement in “W. J. Northcott’s” handwriting.
“2447. Pte. John M‘Cormick, L. T. Corps, age twenty, 11 Company, admitted into 6 Ward, F. Corridor. Admitted with Febris C. C., April 30th, 1856. On or about the 10th of May I was confined in the Garrison Cells, Scutari, for allowing food and drink to be brought to this Patient, by one of Miss Nightingale’s Nurses; and at the time it was brought I were on duty at the Victoria Barracks, Scutari, three-quarters of a mile from the Hospital, and never saw the Nurse, food, or drink that was administerd to the above-named Patient, and I never saw the docter that ordered me to be confind. I was confind by order of 1st Class Staff-Surgeon Prendergast. About two and a half hours after I were aquanted with the case.
“(Signed) 173. W. J. Northcott,
“A.W.M., M S.C.”
1. In defining the office and duties of the Superintendent-General of Nurses, her direct communication with, and qualified subordination to, the Director-General of the Army Medical Department, and, abroad and in war, with and to the Principal Medical Officer of the district, or equivalent, must be very exactly defined. If the formation and government of a body of women to serve in the Hospitals of the Army Medical Department, and in these alone, is contemplated, the less the Director-General and the Superintendent-General have to do with each other, in matters of detail, the better, and the less chance of collision. For very weighty moral and practical reasons, the sole government of the women must belong to the Superintendent-General, and to the Matrons, whom she delegates, and who are themselves responsible and amenable to her. But it will never work to introduce female service into the Army Hospitals, and to leave the Director-General of the Army Medical Department, which, like everything else in the Army, is and must be a hierarchy, no other power in connection with it, than to write and encourage confidential reports against it. There ought to be a definition of the Superintendent-General’s position as regards him, and also, as regards the Principal Medical Officer of the district, abroad and in war. It is useless, and would be dangerous to evade this; it ought to be deliberately settled, and distinctly stated. In the “General Orders” of March 1856, the Superintendent-General’s complete power over the women, and qualified subordination to the Principal Medical Officer, are well and definitively expressed.
It is impossible to appoint the work of the Nurses without the concurrence of the Director-General. It does not do to put a woman into a great ward, or several smaller wards, of men, with several orderlies, without clearly defining her position there. To put her under the orderlies would be to make her being there at all much worse than useless; but she cannot have assigned to her the responsibility of the ward or wards, and consequently, authority over both orderlies and patients, herself being responsible to the Surgeon and Matron, without the concurrence of the Chief of the Army Medical Department.
Nor, without such concurrence, can the duties of the Nurses be assigned. At this moment there are extant two sets of Regulations—the old Army Hospital Regulations, and those of 1855 made for the late Medical Staff Corps. In these Regulations, both the former and the latter, every duty a Nurse can discharge is assigned to different men. The responsibility of the ward, the administration of diets and medicines, the application of poultices, fomentations, leeches, enemas, and minor dressings, are all in so many words assigned as the duties of Assistant-Surgeons, of Hospital-Serjeants, and Orderlies; and of Assistant-Surgeons, of Ward-Masters and Orderlies of the Medical Staff Corps. The Regulations in general are being revised;—so much the better. But the new body of Orderlies, announced in the “Gazette” as the Hospital Corps, will, of course, receive rules from the Director-General; and if these things are not settled with him, there will be contradictory rules in operation, which will most materially thwart the working of the Female Service.
We have ourselves experienced this, as to the administration of medicines, which one Principal Medical Officer took away from the Nurses, saying that it was the duty of the Assistant-Surgeons, in which he was borne out by an existing Regulation. And it would really seem as if this were the intention of the said Regulation, for it is there laid down that the medicines are to be administered twice-a-day, as if this were a property of medicine.
The existence of these Regulations proved also a great stumbling-block in the Castle Hospital, after the war-pressure was over.
Unless the Director-General, and in war and abroad, the Principal Medical Officer, are brought into regular communication with the Superintendent-General of Nurses, by the Rules, they will, at every inspection of Hospitals, revert to the procedure of giving orders and making alterations, which in fact amount to reprimands on the Superintendent-General, and on her Matrons, through the medium of some Clerk or Orderly. There should be, therefore, a distinct channel of communication laid down between the Director-General, and in war and abroad, the Principal Medical Officer and the Superintendent-General of Nurses.
2. Also, and in the same way, there should be distinct rules for direct communication between the Principal Medical Officer of each Hospital, and the Matron, and between the Staff (or equivalent) Surgeons of the Hospital, and the Matron; if not also between these latter and the Nurses.
The constitution of a General Hospital is about to be organized in England. In the large War Hospitals there was the Principal Medical Officer, a Staff-Surgeon in charge of each Division, then the Assistant-Surgeon, who answered to what, as is now proposed, is called the Prescribing Medical Officer of the Wards. As regards the Matrons and Nurses, it must not be proposed to ignore all but these Prescribing Medical Officers. Certainly, it would never do to give the Superior Surgeons of the Hospital no say as to the nursing. In 999 cases out of 1,000, the Superior and older Surgeon is the one who understands and cares much the most about the men, and who, therefore, in the long run, would more appreciate and be fairer to Matrons and Nurses who did their duty by them. The Superior and older Surgeons too, in general, have far more correct ideas of the importance of discipline in a ward, and of the ways of maintaining it, than the Assistant-Surgeons. Moreover, as far as one can judge on a mysterious subject, generally speaking, the older and Superior Surgeon is the honester man. He must be brought into direct communication with the Matron; this will effect good, and prevent mischief. So also let the Staff-Surgeon of the Division, or equivalent, be placed in direct communication with the Nurses of the wards of his Division; this will effect good and prevent mischief. If the Nurse is to trust to receiving the orders of the Staff-Surgeon, through the medium of the Assistant-Surgeon, she will often find herself in a false position.
3. Now, as to the introduction of Nurses into all General Hospitals—this gets rid of many difficulties, but at a fearful cost.
For years to come, the difficulty will be not to extend the work, but to serve such Hospitals as must be undertaken, with respectable and efficient women. The material has, in a great degree, to be created; abundance of applications will be received—the prospect of a pension alone will do that—but the real choice will be very limited. In these Military Hospitals each Nurse must be a Head Nurse, and a trustworthy woman. Many a woman who will make a respectable and efficient Assistant-Nurse under the eye of a vigilant Head-Nurse, will not do at all when put in a military ward or wards, herself the only woman, and Head-Nurse over the Orderlies. As a body, the mass of Assistant-Nurses are too low in moral principle, and too flighty in manner, to make any use of here. Supposing all the Head-Nurses of the great Civil Hospitals[5] offered themselves, there are perhaps not many who could be recommended for a Military Hospital. Some, who are very highly to be thought of, would never bear transplanting into the res dura et servitii novitas of the Army Hospitals. The class from which the Head-Nurses are mainly drawn, tradesmen’s and servants’ widows, &c., will volunteer in numbers, but, in the majority of cases, intending only to lead the idle life of many a London Head-Nurse—“mental, not manual labour”—“Superintendence”—i. e., standing by while the Orderlies do her work and their own. The material has to be created. The rarest powers can do nothing effective in this, in 3, 6, or 12 months. To lay a solid foundation will take the patient, anxious labour of years. To begin with one Hospital would have great advantages. Netley, if it is proceeded with, might be the one, though, in most respects, a Hospital in an ordinary vulgar seaport would be far preferable. Then let the work gradually be extended. It is much more to be feared that the line will be taken of forcing prematurely than of opposing its extension. If it is attempted to occupy all the General Hospitals at once, how is the gratuitous repetition to be avoided of the inevitable misfortune of Scutari, viz., that of beginning on a large scale, with a number of strangers? It certainly should be left to the Director-General to regulate the introduction of Nurses into the General Hospitals—and there is far more reason to fear that he, if unfavourable to the change, will hurry, than obstruct such introduction; indeed it might be better to settle that matter beforehand with the Secretary of State, letting the Director-General be apprised of it, viz., that time is required to effect the gradual introduction of the Female Service with which the Superintendent-General has been charged.
To sum up. A rule must be introduced by which the Director-General is brought into communication with the Superintendent-General, and her qualified subordination to him distinctly expressed. Let the Principal Medical Officer in war also communicate directly with the Superintendent-General or the person performing her functions in the War-Hospitals, and her qualified subordination to him be distinctly expressed. The same with each Principal Medical Officer of a Hospital, and the Matron of that Hospital. No alteration in these Regulations can, of course, be made without the consent of the Secretary of State. In case the Director-General and Superintendent-General finally differ as to any new arrangements, the matter should be referred to the Secretary of State.
The Superintendent-General should issue special regulations for nurses, after conference with the Director-General, and under the sanction of the Secretary of State; also, local regulations for the Matrons with the consent of the Principal Medical Officer and sanction of the Governor of any General Hospital.
If the Matron differ with the Principal Medical Officer, the decision should rest with the Governor of the Hospital.
As to some miscellaneous considerations, of no small importance—
1. It is necessary for a Superintendent-General to have counted the cost, and to be prepared or not prepared to include Roman Catholic Sisters among the Nurses. This will deprive her of some valuable women; of one (speaking for the present time,) who is invaluable; of many decorous, not very useful women. The question is perhaps settled by the fact, that where you have the Roman Catholic Sister, you cannot be secure from the Roman Catholic Direction, with all its many strings, and machinery of opposition. Abroad the cause of the Roman Catholic Church is often the cause of religion; and the Romish Priest serves both zealously at the same time, and with a pure heart. In England, and in matters of England, the first aim of the Direction is too often to damage what is not Roman, and the second to promote what is Christian. Upon the whole I must think Roman-Catholic Sisters are better out of, than in, the Army Hospitals. It would be right to think well over how far they could be entirely dispensed with, in the event of having soon to undertake a War Service.
In the event of a decision being made to dispense altogether with Roman Sisters, it would be as well to be prepared (though we never can speculate on the tactics of the Roman faction, and after what occurred during the Crimean war, it may think it better to take things quietly) for a battle, (not confined to the Army Medical Department,) for the production of an Inspector-General’s letter assigning “reasons” for preferring Nuns to secular Nurses, and for the delivery of sundry opinions of similar purport, ranging from that line to the one taken in the paper emanating from the Army Medical Department, extolling the Russian Nurses, “who were all Sisters of Mercy, and mostly widows of officers.”
2. The nature of the Service and Rules would, unless in war service, perhaps exclude English “Sisters” from the Nurses. They supplied us with some valuable women in the last war, and their Lady-Superior behaved ever generously, loyally, and well towards us.
The principle and detail of most sisterhoods render them unsuited for admixture with the secular element; and the comfortable belief into which the good women (of both branches) practically, if not theoretically, settle, that secular women are too bad to be mended or influenced, unfortunately makes their usefulness among Nurses nearly null. It would never do to unsettle any of the Sisters; but if it so happened that any voluntarily offered to serve as bonâ fide Nurses, some valuable individuals might thus be acquired; but this should not at all be pressed.
It would certainly remove a difficulty in declining Roman Catholic Sisters, if the rule should be to decline also English Catholic Sisters, forming the Staff entirely of secular women.
3. In Civil Hospitals there are three distinct elements of government. First, the Civil Authority; the chief being the Treasurer, or the equivalent civilian, whose subordinate is called diversely Steward, Superintendent, House Governor; second, the Physicians and Surgeons (duly represented, in case of holidays or illness, by the Assistant Physicians or Surgeons), Apothecary and House Surgeon; and third, the chief of the Nurses—the Matron.
It requires of course temper, discretion, forbearance, and fortunate circumstances which do not always happen, for these authorities not to spend a portion of their time in quarrelling with each other; but the ruts are old and deep, and the wheels move on, though they often stick. The Civil Authority is a very important element, especially when the chief is a man of judgment and firmness, who keeps himself paramount over all, and does not delegate all to his subordinate the Steward. The Steward and the Matron generally find their duties disposed to clash.
In some Hospitals the rules are inexplicit in assigning power to the Matron over all the women. But this apart. The Steward represents and wields the police of the Hospital. He progresses through the wards, he perceives, or the Head Nurse reports to him, something disorderly. He rectifies it (or not, as the case and the man may be). She thus, over and above her relation to the Matron, has to appeal to, and to account to, the Steward.
This power of police and discipline, wielded by the Civil Authority of the Hospital, is of immense moment in regulating the good order of the Hospital; it acts in sundry important ways which need not be particularized.
Now, in the case of Military Hospitals, there is one important simplification of the business, which need not be enlarged upon. All the patients are men. But there are two things which do not simplify the machinery of the Military Hospital. The attendants, in the plan proposed, are not (and cannot be) all Nurses, under the Matron; nor all Orderlies, under an Officer; there are Nurses under a Matron, and Orderlies under some Officer; and there is no Civil element. The Doctors both prescribe, and hitherto have governed. An Officer orders flogging, &c.; but the Doctors practically both prescribe, and hitherto have governed. And a Military Hospital must, and should ever remain, essentially different from a Civil Hospital; both different in discipline and detail, and altogether a rougher and ruder place. It should never for a moment be forgotten that the soldier is a very peculiar individual, old and stern as is his trade. A regiment, if one thinks into it, is a curious thing. The Hospital which receives these men when ill and wounded, whether regimental or general, is, and ought to be, a place essentially different in many things from the great Civil Hospital. The moral standard of the patients of the Military Hospital, their readiness to obey, their good feeling to each other, are strikingly higher than in the Civil Hospital; but the soldier is what, amidst all his faults, he has been made by the habit and spirit of discipline, which has become an instinct and a second nature, and which ennobles his own. Relax discipline, and in proportion as you do so, there remains of the soldier a being with as much or more of the brute than the man.
Discipline then being the pivot upon which the good order of all military things, Military Hospitals included, turns, it follows, that if you set down a few women (they should not be many) in a great Military Hospital, unless they can become effectually incorporated into the general spirit of discipline of the place, they will only injure themselves and the whole.
As women, the more entirely they are under the government of the Matron, herself under the government of the Superintendent-General, the better. As Ward Nurses, the more entirely they are under the orders of their Surgeons, the better; but they have not only to obey the Surgeons, they have to enforce the Surgeons’ orders among the patients, and both for so doing, and for the cleanliness, &c., of the ward, they have to give orders to the Orderlies.
In the case where a rule will work, by which, if the Nurse has to complain of an Orderly, she reports the same to the Matron, who lays the complaint before the chief of the Orderlies (whatever may be fixed upon as his name); well and good; but a more direct procedure will also be found necessary.
Every firm and discreet woman (none other is fit for a male ward, least of all for a military ward), will avoid collisions, reports, and violent outbreaks in the ward as much as possible. But still, every now and then these things will happen, and though by all means to be avoided if possible, when they do come, they clear the ward-atmosphere like a storm, provided the discipline be strict. Every now and then—and every experienced Head Nurse will tell the same story—some disobedience, slovenliness, truculence, or sly impudence, will arise in the ward, and she will find she cannot put it down alone. If she remain helplessly deprecating or scolding the men, her position becomes at once an unseemly and a dangerous one, as that of all contemned authority is. In such a case, in the Civil Hospital, the Head Nurse goes straight, according to the nature of the case, to the House Surgeon or to the Steward, unless the visiting hour be at hand, and she judges it best to refer to the Surgeon. Discretion is again here required, as in everything in Hospitals; but between the Surgeon and the Steward, a firm, discreet Head Nurse will generally get the ringleader expelled, and two or three others, named or unnamed, warned of a similar fate. After this sort of explosion, the ward is quiet and orderly for months. The thing is seldom done, but the patients know it can be done at any time, and that it will be done, in such or such a contingency.
Now the soldier cannot be turned out of Hospital, and he knows he cannot. It becomes the more important not to suffer an hour’s relaxation of discipline there. If, therefore, such an outbreak, either on the part of patients or orderlies, should happen in a Military Hospital, the Nurse ought to be able to summon at once the proper authority and afterwards to report the whole to the Matron, but first to bring direct the proper authority into the ward. Whether it be the Captain of Orderlies or the Orderly Medical Officer, or, as in case of emergencies, is generally preferable, the Staff-Surgeon himself, she ought to have power at once to bring the proper authority into the ward, to put down confusion and restore discipline at once, and then afterwards to report to the Matron what has passed.
It must never be forgotten, that in every Regiment we must calculate upon there being two or three thorough scoundrels, five or six men who are not far off from being so, and an indeterminate number whom discipline saves from ranking after them. One year with another, characters no doubt as vile as the worst that disgrace our gaols pass through the General Hospitals.
Another thing to be remembered is, that whatever classification may be carried out, we may be certain beforehand that numbers of patients from a vile cause will be in the ordinary surgical wards of every General Hospital in time of peace. Very severe cases of this sort give heavy work, and little trouble. They suffer much generally, alike from disease and treatment; are frightened, if not ashamed, about themselves; and are generally extra-submissive and quiet. These cases, however, generally would belong to the separated wards; which latter contain usually a large admixture of patients who suffer comparatively little, and who require to be dealt with with unswerving firmness. For reasons somewhat too technical to write, it is to be hoped, upon the whole, that female service will not be, at first, at all events, extended to these wards. The disgusting and comparatively painless secondary condition will, I fear, find its way into the ordinary surgical wards, as it does into the equivalent wards of every Civil Hospital.
All these things would increase the mistake of laying any bar between the Staff Surgeon and the Nurse. In all matters of discipline, generally speaking, the Staff Surgeon will give much more support than the Assistant Surgeon.
A short definite rule should therefore be made, saying whom the Nurse is to summon in the event of disorderliness in the ward.
One thing more. There is nothing more dangerous than to undervalue the objections of opponents. Let us give them their full weight, and while firmly holding our course, and trusting to God to guide it, draw useful cautions from the objections which we quietly and steadily confront.
In the great Military Hospitals, of Roman-Catholic countries, intelligent, well-behaved, Army Surgeons, while explaining everything with thorough business-like precision, if spoken to of the Paris Army Hospitals, before the recently introduced Sœurs de St. Vincent served there, and asked what they think upon the whole of the service of women in Army Hospitals—after a little hesitation, and being urged to speak plainly, will generally say that they prefer in Civil Hospitals the service of Sœurs to those of hired nurses—but they deprecate either Sisters or any women in Military Hospitals. 1. Because the presence of women, however virtuous and guarded, would excite passions and produce unfavourable results in many cases. 2. Because they were unnecessary, the Orderlies being efficient, faithful, kind, and sufficient.
Of the second reason one can judge nothing by a walk through a hospital, as it does not always follow that what the master says is enough is so—though this is one of the mysteries it is good to know and not good to reveal. Of the first there is no doubt. The question remains, striking the balance of good and evil—Do chaste, guarded, and efficient nurses on the whole contribute more to the economy of human life, the order, cleanliness, and decency of a Military Hospital than they do harm? Possibly the former effects are usual and general; the latter exceptional and rare: after all, most soldiers are men and not beasts. But it is well and necessary to bear in mind both the existence of this danger, and the exaggerated fears many Army Surgeons conscientiously as well as unconscientiously have of it.
I therefore very earnestly hope that the work will not be encumbered, at first at all events, with the charge of the venereal wards. And it is most important, for the favourable result of the anxious and difficult experiment about to be made, of permanently introducing female service into Army Hospitals, that we should be quite clear of the convalescent patients, and should only attend patients severely ill or severely injured.
4. Pay and Rations.—In the great Civil Hospitals the Head-Nurses have, on an average, 50l. a-year, no board, an allowance of fuel and light, and the use of one or two, generally unfurnished, rooms. The Assistant-Nurses, on an average, receive about 12s. a-week, [£31 per annum] no board, lodging, with the use of some furniture, sometimes an allowance of fuel and light, apart from the use of both in the wards.
Both Guy’s and St. Bartholomew’s Hospitals now give partial board to the Assistant-Nurses, and St. Thomas’s is about to adopt the same plan.
St. Mary’s Hospital gives board to both Head and Assistant-Nurses.
In the last war Her Majesty’s Nurses received, on an average, 18s. a-week, lodging and board, fuel, light, and partial clothing—18s. a-week is 46l. 16s. yearly. Incorporated into a permanent Service, and with a pension, they ought not to receive the latter amount until after approved years of Service.
It is certainly a different thing to undertake service in a Hospital in Smithfield or the Borough, and to undertake to go, at a moment’s notice, to any part of the world. But the Army Service involves this; and the pension it involves makes a reasonable equivalent for the additional wear and tear of climate, travel, &c. Going abroad is a regular part of the Service undertaken.
Any artificial inducements should be avoided; at the same time their condition should be made a comfortable one. Wages, say 20l., rising to 50l. a-year, rations, an allowance of fuel and light, and a small furnished room, would be enough, and not too much. To this should be added a fixed annual gift of a few strong articles of regulation dress;[6] avoiding multiplicity, and securing the things being all good of their kind. In the last war they had too many things, and some were rubbish. They ought to be well able to supply themselves with linen, shoes, &c., whether at home or when ordered abroad. The articles to be given annually should be three strong dark gowns, six strong aprons, six caps, six collars, one bonnet—and let the things be good—biennially or triennially, one summer and one winter cloak. In India, &c., this might be modified. Their room should be furnished, because, in removing to and fro, it is better to release them from the cares and the pretences of furniture; also, because, instead of many gimcracks, you can thus furnish their rooms with a few comfortable, strong, plain things, presenting a certain military simplicity, which ought to pervade a Military Hospital.
Their wages abroad should not be increased. Whether they serve at home or abroad concerns the Superintendent-General alone, and is no merit or title for additional advantages on their part.
If the principle of rations is considered preferable by the War Department, it is important to give no extra trouble that can be helped. If not, it is to be considered whether or not it would be well to get rid of the rations, in the three kingdoms at all events, for these reasons:
(1.) These women are Head-Nurses. They will think themselves more comfortable “finding themselves” than managing on the substantial and somewhat unvarying provisions of the rations. Some take coffee rather than tea; some tea rather than coffee; many would rather pay for white sugar than not pay for brown. Considering the nature of nursing-work, when faithfully done, it is better they should enjoy and be refreshed by simple meals to their taste than by unpalatable larger portions; especially if the former can be done at no additional cost or trouble to the Queen.
(2.) You thus relieve the Superintendent and Matrons of all communication with the department of the Purveyor-General; of all the mistakes, accidental or otherwise, which might occur; of all complaints of quantity or quality of provisions; of amenities such as those experienced at Balaclava General Hospital, &c., &c., &c.
Of five London Hospitals, the three endowed Hospitals pay all their Head-Nurses in money, and give no board. (This is strictly correct, although, to avoid a long unimportant detail, I have simplified things in this paragraph, and in the two concerning the pay of Head-Nurses and Nurses.) The London Hospital gives its Head-Nurses wages, and a fixed quarterly payment vice the rations of bread, meat, and vegetables, to which they are by the rules entitled. This change was made not very long ago, to end the frequent complaints of quantity, quality, and price, made, perhaps with foundation, by the Nurses. The Westminster Hospital paid its Head-Nurses partly in money, partly in rations of cooked provisions, and there were repeated and general complaints of the quality, quantity, and cooking of the provisions issued to them.
It is therefore to be considered whether the simpler and better plan be not to give the Nurses a fixed money payment, and let them “find themselves,” unless the War Department object to rations not being issued in part payment.
Abroad in many cases, in war in all cases, rations would be desirable. A fixed calculation as to expense should be made.
Experience and consideration will probably give rise to the following conclusion—except in war and in retired stations abroad, not to have Rations; still less to let the Nurses “find themselves,” for the following reasons:—(1.) It is important that the Nurses should not have this excuse for being absent from their duties—“that they have been to get provisions.” (When absent, it should be in pursuit of health and exercise.) (2.) If the Nurse is to cook for herself, greater accommodation will be required than the one room recommended, otherwise the necessary cleanliness cannot be observed. To commute the Rations for mess-money, to put this mess-money in charge of the Matron, wherever there is a market; wherever there is none, to let her “draw” for such provisions on her own indent, as she thinks best, upon the Purveyor, appears to me the safest course. For with regard to this question of dieting the Nurses it should never be forgotten that, in all cases (how much more in those where great physical fatigue and mental anxiety are involved) that principle is the best, if such can be established, which settles diet with a view to producing the highest physical efficiency. Variety and mode of cooking are two essential elements in this. And there can be no doubt that, if a Matron will take the trouble to consult the tastes of her Nurses, together with the above conditions, a better diet might be laid down than could be secured by leaving them solely to their unassisted vagaries and ignorance of what is really the best diet. Community of cooking also implies economy. Also the Nurse ought not to be permitted to starve herself, to save money. Her time is too valuable to allow of her cooking her own dinner; but she should always prepare her own breakfast and tea, when and of what she prefers herself, if she feels inclined to do so.
Where, however, the system of rations must be adopted, three ways remain of working it:—
(1.) Let each Nurse receive, and cook her own rations.
(2.) Let the rations be delivered en masse to the Matron, who has them cooked, sending her proportion to each Nurse.
(3.) Let the Matron, requiring a small payment to cover expenses, arrange that each Nurse can receive her dinner cooked as she wishes it. There is something of this sort at the London Hospital; where the Nurses (and Assistant Nurses) have the right of sending their joint to be boiled or baked in one of the kitchen stoves.
Of these different ways, the first would be liked best by the women—a thing to be considered, in subordination, and as a help to their respectability and their efficiency—still it is, for some reasons stated above, objectionable. However, in this, as in far more important things, it is essential to consider everything as tentative and experimental for some years to come. Do not be fettered by too many rules at first: try different things, and see which answers best.
With regard to rations, it is as well to explain that there were two ways of drawing them for the nurses during the war. In some of the Crimean Hospitals, it was arranged that the same ration should be drawn for a Nurse as that appointed by Regulation for a Medical Staff Orderly. This answered, as may be supposed, exceedingly ill. There was considerably more of some articles, such as bread and meat, than the women could eat; and the surplus had to be wasted or returned to the Purveyor—a serious complication. Of some articles, such as tea and sugar, there was as much too little; and these had to be drawn as extras, except such as the Superintendent-General found it easier and more simple, as she generally did, to provide herself.
The other method was for the Local Superintendent to draw daily on the Purveyor for such articles as she judged necessary; and by thus drawing en masse, a considerable saving was, of course, effected for the Queen, the tastes and health of women were consulted, and there was no complication of accounts.
Where rations are to be drawn at all the latter method should be always followed; and as the former might be understood by the word “rations,” it would be better to call them by some other name, as it must be obvious that such a method could never answer for women.
The experiment which I should wish to try, by which greater variety could be secured, but which could only be practised where there was a market at hand, would be for a commutation to be made of rations for money. Each nurse to supply her quota of “mess money,” the “mess money” to be all expended on the “mess,” and the Matron to manage the “mess” day by day, and arrange for the cooking to be done in common. If each nurse’s dinner is to be cooked separately, it necessarily entails great waste of nourishment. The Nurses would not like this so well as “finding themselves,” but it would ensure them a far better diet.[7]
It would be a question whether the Queen should pay the Superintendent-General so much for each Nurse’s wages, and so much for board, the latter to be retained by the Superintendent-General, or whether the Superintendent-General or each Matron, with the Superintendent-General’s consent, should arrange with the Nurses. This is important, as which ever way it is settled, there must not be disputes between Matron, Nurses, or still less Superintendent-General, as to what amount of wages is to be allotted to the board, or what savings can be effected in the coals, &c.
On the whole it would seem best for the Nurse’s pay to be so much in money for herself, and so much in money for food into the Superintendent-General’s hands. But the question of how much is a serious business.