Nursing the insane

Front matter

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Preface

Within the memory of the passing generation our institutions for the insane have undergone remarkable changes in aims and character. From being merely places of detention and custody, they have evolved into modern hospitals which aim to provide comfortable, pleasant, and hygienic surroundings for the patients, scientific treatment directed to the cure of the curable, and judicious and humane care for all.

A large number of the population of every State hospital is composed of chronic and presumably incurable cases, but many are susceptible of marked mental improvement, and some of recovery.

These patients make up a large community of peculiar and trying persons. To deal with them wisely and kindly requires exceptional qualities of mind and character. The training of nurses and attendants for these patients must cover a much wider field than is comprised in the course of the ordinary trained nurse. The nurse for the insane must be prepared to care for the ordinary medical and surgical diseases of her patients, in addition to their mental ailments; for insanity does not exempt them from the other ills that flesh is heir to. She must safeguard them from injuring themselves or others, must possess many of the qualities that make a good teacher, since a part of her duty is to help correct faults in early training and development, and to encourage and train to correct and useful habits and proper behavior ; she has also to employ and entertain her patients, under the direction of the medical officers ; and to her is intrusted that almost constant association and companionship which, if sympathetic and judicious, is one of the most potent means of restoring her charges to mental health.

To this end training schools are now established in all the State hospitals, where students receive special experience and instruction in the care of mental invalids, in addition to the

vii viii PREFACE

training ordinarily afforded in general hospitals. This instruction is furnished by text-books, lectures, demonstrations in the operating room, and special clinics at the bedside and on the wards.

This book, which started as a collection of familiar talks to nurses in charge of mental invalids, is the outgrowth of fifteen years' experience in a large hospital for the insane. It does not pretend to cover the entire field of nursing, although many points in general nursing are necessarily included in it. Its aim is to furnish special instruction and suggestions to students engaged in caring for the insane, to help new workers to a right beginning, and to aid the more experienced ones to greater efficiency.

Since my work has been almost entirely among women patients and students, it has seemed natural to address myself to women nurses, although many of the talks themselves were originally given to both sexes, and, in the main, are as applicable to men as to women nurses.

I am aware that there is some repetition of ideas in the book. Written at different times and for different occasions — for probationers, junior, senior, and graduate nurses — it is perhaps inevitable that the work as a whole shows emphasis and reiteration along certain lines. But the things emphasized, the topics that reappear in the various talks, are things, I believe, of vital importance; and the principles I have tried to set forth seem to me so much in need of emphasis that I trust the various ways of presenting them will prove sufficiently helpful to excuse whatever repetition may be noted.

The medical works and books on nursing which I have consulted in the preparation of this volume are too numerous to admit of special acknowledgment ; nevertheless, their help is gratefully appreciated. I am also much indebted to several of my confreres for valuable aid in the critical reading of the manuscript.

If this book fulfills its aim, I shall feel it a privilege to have been in any way helpful to that noble body of men and women engaged in the humane service of ministry to minds diseased.

CLARA BARRUS

Contents

CHAPTEB *AGB

I Outline of Nurses* Work in the New York State

Hospitals 1

Chapter I Outline Of Nurses 7 Work In The New York State Hospitals

There are thirteen State hospitals for the care of the insane in New York State, besides two for criminal insane, and twentythree licensed sanitaria. In these institutions are treated more than twenty-eight thousand mental invalids. This number does not include the voluntary patients in unlicensed sanitaria, nor the patients being cared for in private households.

With, then, this large number of mentally afflicted to be treated in New York State alone, it would seem desirable that thorough courses of instruction and training should be afforded the young men and women undertaking this humane but arduous work. Such instruction the State hospital training schools aim to furnish.

The State hospitals are under the control of the State Commission in Lunacy (a body composed of three commissioners, aided by a secretary, a medical inspector, an auditor, and a treasurer), whose official headquarters are in Albany, New York.

Applicants who wish to enter the State hospital service may address communications to the Commission, or to the superintendents of any of the hospitals named below : —

New York State Hospitals Address

Utica State Hospital, Utica, N.Y.

Willard State Hospital, Willard, N.Y.

Hudson River State Hospital, Poughkeepsie, N.Y. Middletown State Homeopathic Hospital, Middletown, N.Y.

Buffalo State Hospital, Buffalo, N.Y.

Binghamton State Hospital, Binghamton, N.Y.

2 NURSING THE INSANE [Chap. I

New York State Hospitals Address

St. Lawrence State Hospital, Ogdensburg, N.Y.

Rochester State Hospital, Rochester, N.Y.

Kings Park State Hospital, Kings Park, L.I.

Long Island State Hospital, Brooklyn, N.Y.

Manhattan State Hospital, Ward's Island, N.Y.

Central Islip State Hospital, Central Islip, N.Y. Gowanda State Homeopathic Hospital, Gowanda, N.Y.

The requirements for entering the service of these hospitals are as follows : men and women of suitable age, preferably from twenty-one to thirty-five, of good character and in sound health, who have passed a non-competitive Civil Service examination at the hospital they wish to enter.

Application blanks may be procured at any of the State hospitals, and at least two satisfactory letters of recommendation must be submitted by the applicant, who needs, of course, to possess a common school education in order to pass the preliminary examination.

On entering the service, the probationer, who is called an attendant, may wear ordinary clothing for one month, after which time, if his or her services prove satisfactory, the appointment is usually confirmed, and the prescribed uniform must then be procured and worn at all times when on duty.

Board, lodging, and laundry are furnished in addition to the wages, which will be mentioned later. In some cases, by special permission of the superintendent, and approval of the Commission, employees are allowed to board and lodge away from the hospital, and then a uniform rate of $12 a month is added to the monthly wages. Such employees are not entitled to the use of the laundry.

Employees who are off duty as a result of illness not received in the fine of duty are not entitled to compensation for time lost.

Attendants and nurses may be dismissed for disregarding rules or for unsatisfactory services. They are expected to present written resignations one month in advance, if intending to leave the service.

The Training School for Nurses aims to offer instruction in

Chap. I] NURSES* WORK IN NEW YORK HOSPITALS 3

the general care of the sick and special instruction in the care of mental and nervous patients. Attendants showing fitness for the work are earnestly urged to enter the Training School, which holds its entrance examinations in June and early in September in all the State hospitals. A two-year course of lectures and recitations in anatomy and physiology and in general and special nursing, supplemented by practical ward and infirmary work, and hygienic housekeeping, comprises the training. Lectures and recitations last from October 1 till May 1, while the practical work continues throughout the year. Oral and written reviews are held from time to time during the year, and a written examination is held at the year's close. At the end of the two-year course the successful candidates are graduated and appointed as nurses, receiving a State diploma, and an increase of pay if they remain in the service. Postgraduate instruction is also provided in many of the hospitals, in which graduate nurses are helped to more advanced studies than are arranged for in the regular course, and where matters concerning which they have grown rusty or indifferent are brought to their notice.

Applications are frequently made to the State hospitals for nurses trained in the care of the insane, and these hospitals occasionally supply the demand from their list of graduates who are engaged in private nursing.

Nurses and attendants are entitled to an annual vacation of fourteen days; to each fourteenth day after the morning's work is performed, or its equivalent; and to each third Sunday; with full pay during such absences. Night nurses and attendants are not entitled to the fourteenth day. Other absences are granted at the discretion of the superintendent.

Nurses and attendants are graded as follows : — Monthly Wages : —

Charge nurses: men receive $35.00 to $41.25; women, $28.75 to $35.00.

4 NURSING THE INSANE [Chap. I

Dining room attendants : women, $17.50 to $22.50.

Special attendants: men, $37.50 to $43.75; women, $31.25 to $37.50.

Increase of wages from minimum to maximum are at the rate of $1.00 a month for each six months of continuous service.

Transfer of employees from one State hospital to another maybe arranged only by obtaining the written consent of the superintendents of the two hospitals, and in such cases only may the service be regarded as continuous. Discharged employees from one State hospital cannot obtain employment in another without the written approval of the superintendent who discharges t>em.

Our large institutions for the insane are managed a uniform system, and while there are individual differences in the various institutions, the rules and requirements, the aims and the advantages, are practically the same in all. The Commission in Lunacy is over the entire hospital service ; the superintendents have charge of their respective institutions ; they are aided by assistant physicians, stewards, matrons, supervisors, nurses, attendants, and other employees.

The patients, both public and private, acute and chronic, are cared for in the various buildings arranged for their care, in some cases in large structures accommodating a great many, in others in detached cottages, accommodating only a few. Most of the State institutions combine these two methods of housing their patients.

The large buildings contain the administrative quarters, often various industrial departments, the culinary departments, etc. The buildings set apart for the use of patients are usually divided into wards or halls, leading off from which are rooms arranged for one, two, or more patients. On each of these wards, or halls, as a rule, in addition to the rooms above-mentioned, are sitting rooms, dining and serving rooms, dormitories, bath and toilet rooms, linen rooms, and a hospital or infirmary department, where the physically sick, the feeble, and those needing bed treatment are cared for, these cases being under the continual supervision of nurses both day and night.

Chap. I] NURSES' WORK IN NEW YORK HOSPITALS 5

The nurse in charge of a hall, together with a sufficient number of assistant nurses or attendants, usually rooms on her particular ward; the other nurses and attendants occupy rooms provided for them at the Nurses' Home, detached from the buildings occupied by patients. Meals for nurses are, as a rule, served in the dining rooms provided for patients, but at different times than when the patients are congregated there.

The proportion of nurses and attendants to patients is about one to nine. In the hospital most familiar to the writer, where the number of patients at present is 1340, the number of men nurses and attendants is 77, of women, 81. The force is considerably reduced at night, when a much smaller number is sufficient to look after the same number of patients.

For the most part, women nurses and attendants are employed on wards for women patients, and men on wards for men patients, but it has been found advantageous in many of the hospitals to employ, in addition to the men nurses and attendants, some women attendants for the men's wards also. In many instances, the women so employed are married, and work in company with their husbands on the same ward.

The duties of nurses and attendants may briefly be stated as follows : To familiarize themselves with, and faithfully obey, the rules of the hospital in whose service they engage; to promote the welfare of their patients in respect to bodily, mental, and moral needs; to strive to be loyal to superiors, and considerate and helpful to associates; to refrain from mentioning patients' names, histories, or peculiarities to people outside the service, and from gossiping concerning patients, employees, or officers with any one, inside the service or out.

Chapter II Introductory Talk To Nurses Of The Insane

I would have no young man or woman lightly engage in nursing the insane. It is work that claims the best of one's powers.

The ideal nurse is one whose bodily presence breathes health and cleanliness, one of quiet garb, of noiseless step, of soothing hand, of cheerful spirit, and of hopeful heart, and one of ready but judicious sympathy. We must not forget the " low and gentle voice " which, if it be " an excellent thing in woman," is especially so in a nurse.

To these qualities must be added punctuality, truthfulness, patience, obedience, caution, courage; a spirit of untiring helpfulness, a vigilance that never sleeps, a sympathy that is inex haustible, and a tact that can cope successfully with the most trying and complex of situations.

The nurse for mental and nervous invalids needs to be especially careful to conceal prejudices, to beware of showing favoritism, to conquer resentment and antipathies, to study the art of peacemaking, to learn when to speak and when to refrain from speaking, when to act and when not to act. She must learn humility and forbearance; in short, she must so cultivate the virtues that she becomes but little lower than the angels. And here I am reminded of what George Eliot says: —

" To be anxious about a soul that is always snapping at you must be left to the saints of the earth/' and you are no saints, but just mortal men and women who have undertaken a work that makes continual demands upon your moral as well as your physical strength. I would not have you think I underestimate these demands. I would only try to help you cope with them as I believe you wish to do, worthily and well.

I wish in this talk to engage the attention not only of beginners in the work, but also that of all nurses and attendants for the insane, to the end that each asks herself whether she is doing her utmost to bring about recovery in recoverable patients, and to ameliorate as far as possible the condition of those who must spend the remainder of their lives in some institution for the insane.

I wish at the outset for each of you to think for a minute what this means — to be always under lock and key, deprived of liberty, subjected to the necessary rules of a large institution, to the authority of the superintendent, and the other attending physicians, to the directions of the supervisor, and sometimes also to the tyranny of attendants, who too often exercise an unwarrantable dictation over patients whom they are expected to care for, to guide, to console, and to encourage, but never to dictate to nor command.

The progressive nurse is always on the alert to learn how she can grow more and more efficient, and here I wish to caution the experienced nurse against thinking there is nothing else for her to learn, no newer and better methods to adopt, no truer application of the old methods.

Those of us who have been in the work many years have to acknowledge that some patients get well in spite of, rather than because of, our efforts; and that others drift into chronicity because we are wanting in the energy and resourcefulness to rouse them to activity and to mental restoration. Have we not seen patients that have been regarded as hopeless, unaccountably take a favorable turn and surprise every one by getting well ? Surely such may be said to recover in spite of us; some subtle influences have been at work of which we are not aware. These experiences make us see the necessity of studying into and revising methods needing revision, and of discovering new methods waiting for discovery, perhaps so near at hand that we are looking right over them, though earnestly desiring to see them.

We need to keep step with the advance being made in the study and treatment of nervous and mental disorders. Antiquated ideas and methods must be cast aside for newer, more enlightened views and methods; routine must give place to individualization. The necessary red tape of an institution must be supplemented by variety and freshness. We must get out of ruts, look at our patients with a fresh eye, and bestir ourselves to try something different if old ways have proved ineffectual.

In our large institutions, it is true, the majority is made up of chronic and supposedly incurable patients, and "to expect a cure when a cure is logically impossible, is illogical." This is a truth we have a right to console ourselves with when we see, in spite of the utmost care, that a patient has drifted into the condition of chronicity. But be sure that the patient has received your utmost care, your best efforts, your unfailing efforts, to stimulate and to restore. Even then, be careful how you regard a given case as incurable. Better err on the side of hoping against hope than to relax in any particular efforts toward bringing about a recovery. Keep alive your own optimism even in the face of discouragement. Optimism is infectious.

One sometimes hears a nurse say: "It is so discouraging caring for these chronic cases. If we could only have something worth working for ! " Let me again and again warn you against regarding a patient as incurable; but, even granted that a given case is hopeless, or, suppose your entire service is composed of seemingly hopeless cases, what then? In the first place, it is your duty to minister to a chronic patient's physical wants just as conscientiously as though she were the most promising of patients. The bodily functions should be regularly and closely watched, and any irregularities promptly reported to the physician. Do not take it upon yourself to decide as to their importance ; let the physician do that. Your duty is to observe and report. The patient's appetite, the sleep, the functions of urination and of defecation, the menstrual function, the condition of the skin, the habits, tendencies, false beliefs, conduct — all these, and many others not enumerated, should be intelligently and regularly scrutinized by you, and any departure from the normal promptly announced to the attending physician.

Because a patient's reason is dethroned, is the need all the more urgent that her body receive the strictest care of the nurse, so that it may be rendered as wholesome, tidy, and unobjectionable in every sense and to every sense, as possible; not by spasmodic, spiritless efforts, but by continuous, tireless, persistent efforts.

" She has been that way for years," " She never brushes her teeth," " She will put butter in her hair," " We can't keep her from destroying her clothes " — familiar sentences, are they not ? Do you ever think how often you confront the physicians with such replies when they urge you to try to bring about a more desirable state of affairs?

Instead of offering such stock answers, how would it do if you said to yourself, " Because she has been that way for years," or " Because she has this troublesome propensity," or " Because she is so negligent, disgusting, or unruly," " I will set my wits to work to counteract these tendencies, to break up these habits. I will begin work on some different line than has been adopted. I will get her into some new ruts at least. I will no longer stand by and say, 'Because she is that way, she shall continue to be that way.'" Beware of the attitude that shows strict adherence to the Biblical injunction, "Let him that is filthy be filthy still," but rather by a word in season and out of season, by line upon line, here a little and there a good deal, by precept and example, seek to instill into your patients a desire for correct behavior, for doing things "decently and in order," for "ways of pleasantness" and "paths of peace."

Try new and radical means for breaking up old habits. What transformations may result ! If every one of you were to work at these reforms with real energy and enthusiasm, your own ingenuity, tact, "mother wit," industry, patience, and perseverance would accomplish wonders! But it must be undertaken earnestly and honestly.

" Susie, button your dress," " Katie, tie your shoe," " Mrs. B., don't follow the doctor down the hall," and the like, uttered in a forceless, half-hearted way — such a method is just so much water on a duck's back; it is even worse than useless, for by uselessly calling attention to it, it only serves to strengthen the brain impression of the particular fault, and it only lets you delude yourself that you are disciplining the patient and mending matters, whereas you have left the condition unimproved, plus the fact that you have actually aided the patient to persist in undesirable conduct; yet you really wish to aid her to desist.

How would it do, for example, if, other efforts having proved unavailing to prevent, say, a patient from putting butter in her hair, you applied to the physician for a small box of vaseline for the patient's personal use ? The chances are that this attention would please her, notwithstanding her deterioration, and that she would take kindly to the substitution — some oil being the main thing desired in this connection. The comfort to your own olfactory sense by this substitution ought to be enough reward, even were there no other consideration.

It is surprising, too, for example, how in the matter of using a toothbrush, a painstaking nurse can inculcate habits of tidiness even in the hopelessly demented. She can sometimes appeal to a patient's vanity, sometimes mention. what a difference clean teeth make in the taste of one's food, or in the influence on the breath, or, if none of these avail, she can as a matter of routine see that such patients attend daily to this part of their toilet just as she should that they attend to their other needs, to the bowels, the food, medicine, and exercise; for there is a large class of patients in which all these wants have to be superintended by the nurse, and to say that a patient never brushes her teeth, for example, is no excuse whatever. If she does not, the nurse is there to see that it is done, or to do it for her when she proves intractable.

There is no need to multiply examples. Each case calls for a fresh application of energy, ingenuity, and perseverance on your part, and in just the degree that you show yourself active, resourceful, and indefatigable in meeting these trying questions, in just that degree will your value be felt as an efficient nurse.

I always feel that a nurse is honestly willing to better conditions if she meets suggestions with a cheerful, " I'll try, Doctor," instead of that everlasting answer, "It is no use trying — you can't do anything with her" By the nurse's willingness to cooperate, she puts herself in the right mental attitude to gain the victory over the point in question; she has taken the first step necessary — the step of conquering her own indifference in the matter. She is therefore in a position to put her wits to work, to summon her resources, and to bring about desired results. It is the old story of "Til Try" conquering where "I Can't" invariably fails. It is incalculable, too, how much more interesting and inspiring you will find the work if this attitude is taken and persisted in, than it is to jog along in a routine way.

I have seen a new and energetic nurse take charge of a room full of chronic patients who had been allowed by a former nurse to eat with their fingers, shoving in the food in a most repulsive way; in a few weeks' time I have seen that nurse's painstaking efforts rewarded by an orderly set of patients decorously feeding themselves with spoons from neatly arranged trays, the same cases that other nurses had declared could not be made to do differently. But this transformation was not effected without patience, perseverance, tact, and a careful study of, and attention to, each individual patient; for what works well with one will often have no effect upon another.

There is always this point to be kept in mind, too, that by your efforts you can prevent less hopeless cases from sinking into the dilapidated ways which more extreme ones have adopted. The latter patients should furnish a constant warning to us to leave nothing untried to prevent such a result.

There are other duties to be performed for the chronic patient besides looking after the bodily health and appearance. Her comfort and enjoyment are none the less important because fate has deprived her of some, even many, of her faculties. The more she has been deprived, the more is it your bounden duty to help compensate her for this loss. Her tranquillity, happiness, desires, even her harmless whims, should be ministered to as far as in you lies, always keeping in mind the patient's good in judging how far you can indulge her, and, in addition, the greatest good to the greatest number, not, of course, catering to the whims of one person to the annoyance of many others.

Because a patient is deluded and unreasonable, you are not excused from taking precautions, or from resorting to expedients which might serve to maintain or to bring about serenity of mind and peaceableness of behavior, even though you cannot hope to dispel the delusions giving rise to troublesome conduct. Suppose a patient likes to cut out and save favorite poems or pictures, or other clippings from the magazines. If she can be trusted with scissors (blunt-pointed, of course), there is no reason why she should not be allowed to do this. The things she saves may be worthless in your eyes, intrinsically worthless, perhaps, but think what they mean to her. Think what that little bag which contains her sole stock of treasures means in her life, you who have your liberty, your friends, your rooms with bookshelves, dressers, wardrobes, and places wherein to keep belongings! Think, and be careful how you ruthlessly destroy or ridicule her poor little possessions ! I know of no more pathetic sight in an insane hospital than these pitiful little woolen or cotton bags that many of our patients concoct out of scraps of cloth obtained by hook or crook, in which they store their small belongings, not even in some instances having any place to keep them except hanging on their arms by day or tied on the bed or tucked under the pillow at night. It is the longing for a home, for a place of one's very own, that still survives in the beclouded soul — a remnant of individuality which we should all respect as far as possible.

In every way that lies in our power we should seek to individualize each patient; keep him alive to his own personality; do not class him as one of a mass; he has his individual life to live, his own hopes, fears, and desires; his own place in creation; and it is our duty at all times to respect this, to help him to appreciate it, if, by reason of his disordered intellect, he is in danger of forgetting it. Always call patients by name, do not speak of them as "he," or "she"; let each feel that he is somebody, a particular somebody — not a mere something, grouped in a mass and called "the patients." I was touched some time ago when a patient who had been with us for several years returned from a visit home, bringing with her one of these little bags above mentioned. Seeing her cling to it as fondly as ever after her sojourn in the world, I made some comment which led her to show me the interior of the shabby receptacle. I have forgotten what made up the bulk of the things; I recall, among the odds and ends, some letters written by her little girl telling of her standing in school; but what impressed me most was a withered rose that had been given her years before by one of the hospital physicians — carelessly given on his morning visit. The discovery of how that chance act — the bestowal of the rose — had given to the afflicted one a veritable treasure, showed me how little it sometimes takes to make patients happy, and how our casual acts and words often carry comfort, or alas ! cause distress that we but dimly recognize either at the time or afterward. One must, however, consider something besides sentiment in this matter. The question has its practical side. Some of you, I know, will immediately think of patients with a propensity for collecting things, and will wonder if I mean that they are to be humored to the full extent of these proclivities. Of course not. This is where common sense and tact must be exercised, though even with such cases I should say, rather err on the side of indulgence than of arbitrary prohibition. A certain nurse gets around this matter tactfully by permitting collections to be made till they reach a considerable size, when the package is tied, labeled by the patient, and sent to the office of the superintendent, and the patient goes on contentedly accumulating others which in time meet the same fate. She knows that when the package reaches a certain bulk it must be carried away; she is happy in the belief that her treasures are safe, and is so intent upon acquiring others that she does not inquire for the old packages after they have passed out of her keeping. No harm is done in catering to this whim, and the capacious wastebasket relieves us of the worthless hoard.