Handbook for hospital sisters

Front matter

Han dbook

FOR.

FLORENCE S. LEES

Preface

Among the social changes in England during the present century none is more remarkable tli an the increased desire for systematic care of the sick poor. It is not implied that the humane and religious care of the poor had not been among the chief works of mercy of pious persons generally, and of the religious orders in particular, for centuries past. But since the suppression of the religious orders, and especially since the rapid increase of population produced by our manufactures, it must be allowed that the State has found great difficulty in adequately supplementing the action of private charity towards the sick, and that private charity has been unequal to the task of systematically supplementing the stern economy of the State.

But this period we may hope is passing, and nothing is now more encouraging to philan-

Vlll

PREFACE.

thropic political economists (for such there are) than the attempts made in every direction to secure such a national organisation as shall reduce to a minimum the preventable sickness among the poor, and reach every needy sufferer, without waste of strength or waste of means.

The present little volume is an attempt to strengthen one corps in that army which is battling with the evils that prey on our great urban populations, or which desolate the rural homes of our agricultural classes.

Completely to appreciate the place of nursing in our body politic needs a little attention.- Miss Nightingale first startled this country by making familiar the idea that a cultivated woman of gentle birth could safely leave a wealthy home for the lines of a sickly camp, and staunch the wounds and tend the fevers of an army in the field. She first showed how great a work is here for woman, but at the same time how requisite are training, instruction, and organisation.

Her writings as well as her practice show this. Her “Notes on Nursing,” * her “Notes

* “ Notes on Nursing : What it Is, and What it is Not.” By Florence Nightingale. London : New Edition. 1S60.

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PREFACE.

on Hospitals,”* her remarks in the Report of the Cubic Space Commission f with respect to nursing in workhouses, her regulations for the Nursing School at St. Thomas’s Hospital in London, are but parts of a great landmark she has raised in the history of civilization.

On this landmark there seems to be engraved in clear characters, “Nursing is the medical

WORK OF WOMAN.”

But the nursing there recorded is an art which needs special mental qualities, special culture, and special power of physical endurance.

•Nursing is a department of the profession of

Medicine and Surgery.

It is incompatible with the ordinary practice of the physician and the surgeon, because there is often implied entire devotion by the nurse to a single patient, and sometimes, indeed, the devotion to a single patient of two or of three nurses.

Nursing has, therefore, bec.ome a special subject of education, and the appliances of the Nursing School also are special.

This is at once seen by considering the work

* “ Notes on Lying-in Hospitals. London: 1ST 1 .

t Report of Cubic Space Commission, Lond. 1867, p. 64.

X

PREFACE.

that must be daily done in a large hospital ward —

1st. The common work of cleaning, “ housemaid’s work.” This in a room where there are twenty to thirty sick persons must obviously be constant and laborious if the condition oi absolute cleanliness is to be maintained in person and bed, in all articles of furniture, and all the vessels and apparatus of whatever kind for daily use.

2ndly. The work of tending the sick themselves in every variety and complication ol disease. Wounds to be dressed, posture to be attended to, medicine to be administered, tempers to be soothed, inquiries wisely answered — directions on all these subjects to be received from the physicians and the surgeons with respect to every one, and to be understood, remembered, and acted on, day by day, week by week, the beds never empty, cure or death removing one anxious charge only to be replaced by another — all these demand no light attention, no feeble character.

3rdly. The work of the one organising mind which is to superintend and regulate the steady harmonious action of one or of several such wards.

PREFACE.

XI

The functions, therefore, of a completely skilled nurse are threefold — superintendence, ministration, housework.

The three are distinct only in large institutions. The three must be taught in any complete training institution.

It is the main object of this Treatise to pourtray the proper functions of the skilled nurse — of one who is conversant with all the needs of a ward, is capable of doing all the work, and so of instructing and superintending learners.

It is much to be desired that this subject should be fully understood by the managers of the many hospitals, rate-supported or voluntary, which now exist in every part of the country.

This is not the place for entering at length on the whole question of the relation of “Nursing” to other arrangements connected with national and personal health. It would be unjust, however, both to the author of this Manual and to the reader to omit all allusion to that complex subject.

The “ progress of civilization ” in this country is bringing about a general revision of the external and obvious arrangements which were supposed to constitute the framework of

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PREFACE.

society. * This appears often in an unexpected manner. Half a century ago nothing was more accepted as true than that bleeding was a sinequd non in pneumonia — that all surgeons were men — that cure was the highest function of the physician. We now admit that bleeding is not essential, that surgeons may be women, that in many things, medical as non-medical, we can prevent what we cannot cure.

Thoughtful persons in every department are asking themselves ; in this shuffle of the cards what is the outcome to be desired?

In the matter of nurse training this is certain — that a really skilled nurse in many cases influences at least as much as the physician the result of the illness ; that nursing is therefore a fit object for the employment of great practical ability, as for the exercise of high moral qualities ; that there is here an outlet for the energies and employment for the tender power and skill of good women of almost every class ; that five years or ten years as a nursing sister in a hospital should no more disqualify a young lady for a future and different life than going to the bar for a few years should unfit a man for the life of a country gentleman ; that a woman who,

PREFACE.

Xlll having had a good general education; such as women now get, and having gone well and wisely through the discipline of Miss Nightingale’s school at St. Thomas’s, whatever her destiny in life might be, would adorn it, and prove in the truest sense a blessing to those in whose society she was afterwards placed.

That much is certain. General culture followed by the acquisition of some portions of physical science, and the study of their practical application to the relief of human suffering, the habit of firm though gentle command which a ward sister must acquire, the contact with the administrative arrangements of a great hospital, the interest in the great questions of social organisation which surround the charge of the sick poor, all evoked in a manner essentially belonging to the delicacy and the practical sympathy of woman’s character, would make as they have made noble female characters.

If there be any who think that the life here praised is one which cannot give scope to high intellectual attainment, they had better grapple more closely with a few of the material and psychical questions which arise round the sick man’s bed. Having so grappled they may

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PI? E PACE.

find, as wiser men have found before, how much there is that centres in one life and in one death for him that has eyes to see and heart to understand.

If these brief hints be germs of truth, the development of intelligent and skilled nursing as a profession will prove of incalculable benefit — 1st, to the sick and the poor, in general ; and, 2nd, to women and to the medical profession in particular.

Of the sick and the poor more need not be said. Of women, in relation to the medical profession, just a few words should be added.

The Medical Act of 1858 allows women to be registered as medical practitioners. It makes no provision for the registration of trained nurses, however complete their education, and however great their skill, whether as midwives or nurses.

Many accomplished women might reasonably desire the name as well as the function of superintendents of hospitals, or of ward-sisters, or of nurses. At present they can have no such legal recognition of their qualifications in either department, as is obtained by sisters who become school -mistresses, or who are students and teachers of Art. That this

PREFACE.

XV ought to be remedied can hardly admit of doubt ; but it rests with the women of England to decide whether what is here advocated has their support as well as their approval : or whether the sole relation they will have to the medical profession is to he that of the ordinary licence to practise surgery and medicine as with men. There are signs that some who desire this last, undervalue or despise the profession of nursing in the wide sense of this volume. If these even consulted their own interests they would support and not look down upon what in their view is at all events half way to a higher end.

One remark onlv as to the training schools. In every county where there is a good hospital some effort should be made for teaching nurses, and for the maintenance of a nursing staff for use in the district. As the sanitary organisation of the counties is made complete, the hospitals, whether rate-supported or voluntary, will become a more living part of the net-work which furnishes the health statistics of the nation. To these centres pupil-nurses and teachers may and should be generally attached. Dispensing might properly form part of their instruction, as in such districts much of the

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PREFACE.

ordinary dispensing might be done by nurses who had been duly instructed and certificated for the purpose.

Whether this volume will aid the work thus slightly sketched the reader will judge. Of the practical qualifications of the writer there can be no question. Miss Florence Lees has proved herself to be a worthy pupil of Miss Nightingale. Trained at St. Thomas’s Hospital, as a probationer and nurse, she has studied and worked in Berlin, Dresden, and Kaiserswerth ; afterwards as surgical sister for some months at King’s College Hospital, in London ; subsequently she examined the hospitals of Holland and Denmark ; by the kindness of M. Husson, Director-general of the French Civil Hospitals, she was enabled to undergo further training and have more practice in the LIbtel Dieu, Lariboisiere, and Enfant Jesus, and to visit the chief hospitals of Paris, prior to serving under the Soeurs de Charite of St. Vincent de Paul, in the great Military Hospitals of Val-de- Grace and Vincennes. By the permission of General Leboeuf, the then Minister-of-War, she was enabled to work in every part of these hospitals, and by the constant kindness of M. Michel Ldvy, Director

XVI 1

PREFACE.

of the Val-de-Grace, her training was rendered a most thorough one, from the kitchen and linen -room to the ward-dressings and the operating theatre.

All this done, it became her lot as her desire, to have sole charge of the second typhus station with the 10th Army Corps before Metz, and to move when that was closed, to the Ambulance for wounded of Her Imperial and Royal Highness the Crown Princess of Germany.

These pages record the chief practical conclusions of such an one. I add only that I trust the book may fall into the hands of the Managers of every hospital, and of the Guardians of every Union, as well as into those of the many cultured women who are unofficially engaged, all over England, in the care of their sick sisters and brethren.

Henry W. Acland.

b

Contents

PAGE

PilEFACE, BY Dll. ACLAND vii

Section I. — General Remarks on Nursing ; on the Qualifications of Nurses; the duties of a Ward Sister towards them and to her Superintendent ; and on the beautifying of Hospital Wards 1

Appendix

PAGE

A. — On Studying Cases and Reporting on them, by

Dr. Acland 189

B. — General subjects for Clinical Inquiry, by Dr.

Acland 193

C. — General Directions for the Training of the Pro-

bationer Nurses in taking Notes of the Medical and Surgical Cases in Hospitals, by Mr. Whitfield 198

D. — Diet and Cookery for the Sick . . . .219

HANDBOOK FOR

HANDBOOK FOB

HOSPITAL SISTERS.

Section I

GENERAL REMARKS ON NURSING ; ON THE QUALIFICATIONS OF NURSES ; THE DUTIES OF A WARD SISTER TOWARDS THEM AND TO HER SUPERINTENDENT ; AND ON THE BEAUTI- FYING OF HER WARDS.

Haying been told that I have had unusual opportunities for observing the work of Sisters and Nurses in hospitals, at home and abroad, I have been induced to publish the notes which I made in spare moments, when passing through the course of training, or instruction, at these hospitals. Any one who is at all acquainted with work of this kind, will know

Intro-

ductory

remarks.

u

OBJECT OF THIS BOOK.

Title of book.

Training

nurses

abroad.

how, during the day-time spare moments are rare and precious, and how at night-time the weariness of body acts upon the brain, and urges it to seek repose. I offer this as an excuse for the many imperfections of these notes, imperfections of which I am so deeply sensible, that nothing but the earnest solicitations of one to whom I owe all that I know of hospital work, under whom and by whom I have been trained, could have persuaded me to undertake their publication.

I have given this book the title of “A Handbook for Hospital Sisters,” because in England head nurses of wards are so called ; and my remarks are principally directed to the duties and qualifications of these. Moreover, although many books have appeared in imitation of the first and well known “ Notes on Nursing,” none of them have been written for, or adapted to the requirements of, those who have to train others.

The term “ Sisters ” in hospitals abroad, is applied to the Roman Catholic nurses ; the corresponding term for Protestants is “ Deaconesses.” Of whatever persuasion they may be, they, the Sisters, are obliged in their hospitals to pass through the training of Pro-

DEFICIENCY OF TRAINING ABROAD.

bationary Nurses. This training abroad is, however, different from that given in St. Thomas’s Hospital, and in other schools for nurses in this kingdom ; but there are in Germany two, one at Darmstadt, under Princess Louis ol Hesse, and one at Carlsruhe under the Grand Duchess of Baden, which are justly celebrated for the perfection of their practical and theoretical teaching.

Neither German Deaconesses, nor French Sisters, receive a training thorough in all respects, but they are taught to keep the wards of the sick, as well as everything m connexion with the sick, except perhaps their persons, clean and in order. I never knew a Deaconess, who washed, or saw washed, the feet of her patients, even when, as was the case duung the late war, men came into the wards under their charge and superintendence, who had never had clean socks on for months, nor their feet washed during that time. I have received patients, who had been for several

weeks under the charge of Deaconess Sisters m a state which defies description. Their hair was full of vermin, their feet were encrusted with dirt, and if wounded men, the wounds were dressed only superficially. In

Deficiency of training in sisters abroad.

EFFICIENCY OF TRAINING IN ENGLAND.

Efficiency of training in English nurses.

fever cases, the lips, teeth, and gums were covered with a thick crust (sordes) which had been left on for days.

With French Sisters this never happened ; but, on the other hand, a patient, from feelings of false delicacy, would often be left even by them in the most pitiable condition, unless a male Nurse (Infirmier) was within call, to cleanse and arrange him.

Every trained English Nurse knows that all things can be done for a patient “ decently and in order and indeed, the chief part of the training consists in learning how this should be done. During the late war I had charge of an ambulance for typhus fever, in which there were but few of those articles for the comfort and well-being of the sick, which would in England be considered indispensable, and the number of attendants allowed was of the scantiest. Here the absolute necessity of a previous training was manifest, for I had to do many things for the sick, which in an English hospital could never tail to the lot of any Nurse. Once, one of the poor fellows, "who was sen sible, said, “ Ah, Sister, I do not like that you should do such things lor us, but God will reward you.” I felt then that I was already

NURSING DURING THE LATE WAR.

rewarded ; for what I had dreaded most of all was lest those who were not in delirium, or utterly helpless, should say anything to make my work harder than it already was.

The dread was without foundation ; and yet I do not know what I could or should have done in many cases, had it not been for the very practical training I received as a Nightingale probationer in St. Thomas’s Hospital, when it was at Newington.

During: the late war, many ladies were most Nursing

during the

eager to go out and nurse the sick and late war.

o o

wounded, wishing and expecting to learn nursing in a few lessons, but this knowledge cannot be acquired in a few weeks, or even a few months. A year’s training only lays the foundation for the work of the lifetime which is to succeed it.

An old nurse once said to me, (she was then over seventy years of age, and had served in the Crimea under Miss Nightingale,) “ it seems to me that the training is never finished ; every day I learn something fresh, or see that I ought to learn it.” Those ladies, therefore, were mistaken, who thought a mere desire to help, and a willingness to do what they were told, were the only things necessary to make them

G

NECESSITY OF EXPERIENCE.

valuable assistants to over- worked medical men, who had neither time nor inclination to train those under them.

Dr. Gordon The Deputy-Inspector General, Dr. Gordon, jn the late who was sent out by the War Office to the siege of Paris, laid special stress on this point, and said that although he would most willingly accord all praise and honour to the ladies who devoted their time and labour to the sick and wounded in Paris, yet he must venture to remark 11 that there are numerous circumstances in connection with a state of war, which indicate very clearly the existence of an urgent necessity that military hospital organization should be complete, and consist entirely of persons capable of withstanding the discomforts and fatigue inseparable from war.

Necessity “ The duty of attending upon the sick and

of experi- l i • r , • , • i •

ence in wounded is one ot vast importance, involving ruu'1"°' as it often does, the issues of life and death, and therefore so long as the life of an individual holds that importance to himself and to society which our civilization accords to it, the necessity is paramount of attaining the best security possible against its loss.”

No one but a woman can give those thousand

QUALIFICATIONS.

and one little cares and attentions, which soften the anguish of suffering and disease ; and no one but a nurse can know what cares and attentions are best to bestow, nor how to bestow them.

The qualifications which are required in a nurse are stated at the head of each paper given to the pupils in our Training Schools ; they are —

Cleanliness. Sobriety. Punctuality.

Neatness. Truthfulness. Trustworthiness.

Obedience. Honesty. Quickness and Orderliness.

And she is to be patient, cheerful, and kindly.

And these qualities the Sister must not only exhibit in her own person, but (which is a much harder task) must endeavour to cultivate them in those who are placed under her. I know of no harder task, nor one requiring more Christian love and charity to fulfil it aright. It is easy to get through one’s ordinary routine of duties, but it is sometimes very difficult to make nurses and probationers fulfil theirs. If a sister sees that a nurse really tries to remember and obey the orders which she has received, she will do well to have patience with her for a time, however dull she may be, and merely look carefully over her work.

Qualifications of nurses.

s

BEHAVIOUR.

Behaviour of nurses to patients.

Personal

cleanliness.

I have known a nurse told morning after morning not to forget “that oiled paper or oil-silk were to be placed over the linseedpoultices of her patients ; ” and yet, so little reliance could be placed upon her doing exactly as she was ordered, that the sister herself, after the dressings were finished, had to examine every poultice, to see that the oil silk had not been omitted.

In our nursing-schools, none but women whose character is above reproach are ever admitted, and therefore upon this point remark is little needed ; but the sister should insist that in the wards, and more particularly in a male ward, no immodest jest should be uttered. The nurse should remember that men are keen observers, and quickly detect even the semblance of levity in a woman. Without this watchfulness over the behaviour, a nurse in a male ward will lose that moral influence which she should possess over her charges, and wanting this, no woman is worthy of the name or of the profession of a nurse.

Personal cleanliness, though always insisted upon in our training-schools, is only superficially carried out. I have known nurses whose hair was

PERSONAL CLEANLINESS.

kept in the most disgraceful condition, with the exception of the little in front that was shown.

A sister should, by example and precept, urge her nurses to take a cold sponging bath every morning, and thoroughly to wash themselves with warm water at night.

All nurses, before the arrival of the chief surgeon for the visit, ‘ clean themselves,’ as they term it ; but this cleansing is only for the outward eye, and does not, even in their own phraseology, come under the heading of “ a good wash the latter treat being reserved for Saturday night or Sunday morning.

Nor, as a rule, does a nurse change her Under linen frequently enough. I do not see why it should be impossible to provide nurses with their under-linen as well as their outer dress. •

This is the custom in the hospitals abroad, and the advantages are too obvious to need my dilating on them. Under this rule, and by no other plan, would a sister be able to ensure that her nurses changed their linen, entirely, twice a week ; and no nurse should do so less frequently.

It is sometimes difficult to impress upon Neatness, nurses the necessity of neatness in their own

DRESS.

Dress.

persons, more especially with regard to the arrangement of their hair.

No sister should ever allow a nurse under her charge to wear her hair low down upon her neck behind, or with frisettes or pads of any kind.

The office of nurse is too high and holy an one for any woman called to it to wish to devote much time to the adornment of her person. Her one object as regards herself should be to be clean, simple, and neat, with nothing in her person or attire to attract notice or remark.

In most of our nursing-schools a uniform dress is provided, and ornaments of any kind are strictly forbidden, therefore it is unnecessary to dwell further upon this subject.

Where no special dress or uniform has been yet adopted, I would recommend the brown holland or linen “wrapper,” worn by the nurses in the ambulance of the Crown Princess at Homburg. It was buttoned down the front, and could be worn over any dress, and changed in a minute. The ladies and nurses of the Dutch ambulance at Saarbriicken wore dresses and aprons of the same material, but of coarser texture, bound and trimmed with scarlet

APRONS.

woollen braid, about half-an-inch wide, which had a bright and pretty effect.

A uniform dress in hospital life is a point of no little importance.

It would be better if a sister paid more APronsattention to the cleanliness of a nurse’s apron than is usually done.

A nurse should not be allowed to serve the dinners of the patients wearing the same apron as when she dressed wounds, &c. ; she should be provided with a coarse linen apron to be tied over the other, and used only during the distribution of food.

Further, a nurse or probationer should not be allowed to appear at her meals in the apron which she has worn in the wards; she should be provided with an apron of some daily maternal, which she should be required to wear when “ off duty,” putting it on immediately upon leaving, and off when entering the wards. For this purpose I should recommend dark blue cotton or linen, or black alpaca.

All hospital aprons should be made nearly large enough to go round the dress, with a large “ bib,” or square, in front. This pattern is universally worn by Soeurs Hospitalises

METHOD AND ORDER.

Over-

sleeves.

Method and order.

Ward cupboards.

abroad, and I have heard much ridicule on the subject of the “lady-like” apron worn by sisters and nurses in England, which are certainly more for effect than protection.

I would also recommend loose sleeves ol white linen, or of the same material as the dress, if that material can be washed ; they should be drawn over the other sleeves, and tied above the elbow during the active duties of the ward.

They should not be worn outside the ward at any time.

A nurse must receive the strictest possiole training upon the necessity ol method and order. It is essential, not only that she herself should know where to lay her hand on a thing at a moment’s notice, but that others should know it also. A “ nurse’s cupboard,” as it is called, is usually a confused mass of bandages, linen, splints, pads, pots of ointment, &c., put there in what she calls “ order,” but which would never be so termed in any hospital abroad.

If it be permitted, the sister of a ward should have the doors of the nurse’s cupboard made of glass, as she can then see that only such things arc put in it as require to be kept

MATERIALS FOR DRESSINGS.

free from dust, and that splints, air-cushions, and the like, are on a distinct shelf, where the air may pass freely round and above them.

Linen should be kept on a second shelf in the cupboard, and should be arranged in rolls of various sizes : another shelf should be reserved for prepared pads and splints ; ♦and another for oilsilk, gutta percha, thread, pins; another for catheters, and other small articles, each of which is to be placed by itself, distinct from the other contents. A fifth shelf or drawer should contain bandages alone, arranged in order according to size.

Every shelf ought to have a label neatly gummed on its edge, naming its contents.

On no pretence should any soiled pad be admitted amongst the others ; it should be at once unpicked, and sent to the laundry to be washed and remade.

All greasy preparations for dressings should he kept in neat jars with lids, and should stand on the table where bottles of various medicines are usually kept in store.

The sister should pay special attention to the keeping of these jars and bottles in the most perfect order and cleanliness ; and should

Materials for dressings.

SLOWNESS TO BE AVOIDED.

Slowness to be avoided.

see that the adhesive labels (where such are used) are replaced by fresh ones when soiled or defaced.

Often a sister will have great trouble in preventing her nurses falling into slow, dawdling habits. I have found more trouble in making nurses finish their work efficientlv in a given time, than in almost anything else. A nurse who does not do her work with a certain amount of quickness and precision, will never do it well; for by her lingering too long over one thing, the other parts of her duty suffer.

I have known a nurse give the most painstaking attention to the crockery in the ward, and in consequence leave herself too little time to bestow half the care which was really required for the dressings of the patients. On the other hand, a nurse who wishes to be thought quick, will hurry and bustle everything and everybody in her ward, occasioning much noise and discomfort, without really advancing her work.