SUGGESTIONS ON A SYSTEM OF NURSING FOR HOSPITALS IN INDIA. To the Secretary of the Sanitary Commission for Bengal. Sir, In reply to your letter of November 21, 1864, requesting me to send to you any suggestions which might occur to me regarding the. organization of a system of Female Nursing in Indian Hospitals, I beg herewith to transmit a paper of suggestions which I hope may assist you in considering the subject. In order to supply the requisite number of Nurses for the Hospitals of India, you must have schools for their instruction and training, either in England or in India, or in both. For these schools there must be competent teachers to instruct and train the untaught, and if such teachers cannot at present be found in India, they must be sent from England. Unless it is assumed that the development of excellence in all that relates to nursing will be as rapid and the teaching as good in India as in England, it would be necessary to provide for a continued supply of teachers, that is, of Matrons and Head Nurses, trained at home. No one, probably, who is acquainted with European life in India will doubt that such a continuous stream of fresh blood and advanced knowledge will be necessary to prevent progressive deterioration. Then, if this be so, you will require a sort of normal school in England at which Matrons and Head Nurses may be thoroughly trained for service in India, not merely as Nurses but as teachers of nursing. A great part of the training must be conducted by the Head Nurses, even where there is a Training Matron. There does not appear to be any other practicable mode of adequately supplying what is required. Whether you train in India or not, the Government of India ought to make arrangements for the training, in England, of Matrons and Head Nurses for service in India, on such a footing as may reasonably be expected to supply annually the number required to keep up, to its full amount, the establishment of Matrons and Head Nurses, trained in Europe, which may be considered desirable. The inducements which the Government of India would no doubt be prepared to hold out, would probably attract to their service a very competent and trustworthy class of persons, more especially if it wore, as it probably ought to be, a “ covenanted service ” — - a service in wdiich employers and employed entered into a formal contract or covenant. In that case what the Government undertook to do would be fixed by regulations which the persons entering the service would engage to observe and the Government would be bound to act up to. One of the advantages of making it a regular service would be that you might then, to a limited extent, hold out a prospect of promotion, not of course by seniority but by selection for superior merit and distinguished service, in which length of service wrould be considered. This need not exclude recruiting in India, especially for the ranks. It is probable that in some parts of India persons, either born in this country or of English or Anglo-Indian parentage, and of suitable character and education, might desire to enter such a service, and some of them might rise in it. Such persons might be very useful from their knowledge of the native languages and of local circumstances of which persons arriving from England wrould necessarily be ignorant. One of the most obvious difficulties, in the wTay of carrying out any such systematic organization as is above suggested, wTould arise from the inducements to marry, W'hich 11623. A 2 would beset Nurses of all grades in India, and the consequent danger that the Govern¬ ment might thus lose the services of persons who had been trained and conveyed thither at great cost. A certain term of service in India might be made a condition of employ¬ ment, but if this condition were violated by marriage, dismissal from the service would be no punishment, and would not even involve any sacrifice which the Nurse had not predetermined to make. A breach of the contract might no doubt involve certain penalties, which might be enforced by legal proceedings, but there would probably be a disinclination to prosecute, or, in case of prosecution, to convict or to give adequate damages. Perhaps the best course might be to annex a specified pecuniary penalty to breach of the contract, by marriage or otherwise, the amount to diminish with each year of service actually performed in India. This might go far to reimburse the Government for the loss of service, and might incline both the Nurse and her suitor to postpone their nuptials until the stipulated term of service should have been completed, for I presume that the husband, on his marriage, would become liable for the amount of the penalty, being a debt due by his wife. If the attempt to supply the Hospitals of India with female Nurses is not to be a failure, it is plain that it must be made on some organized plan, which, being based on a stable foundation, may be expected to give permanence and efficiency to the system. Were it as easy to find competent Matrons and Head Nurses as it is to find female mill workers, it may be questioned whether it would be advisable to send out a ship load of them at once, to be scattered over the country from Cape Comorin to Peshawur. To place the majority thus beyond the control and guidance of the heads of their own very special department, would be not only to exclude all hope of efficient and uniform organization, but almost to ensure the failure of the majority of them, and with it a discreditable break down of the whole system. But this is a danger that cannot be incurred, for the Nurses do not exist, and years must elapse before a sufficient number can be “ made ” to supply the Hospitals of India. There is therefore ample time and opportunity to devise a suitable scheme and to pursue it in a tentative manner, correcting and adjusting it as the experiments are being worked out. At how many stations in India it wrould be desirable to institute such tentative trials of nursing would depend not only on the local circumstances, but also on the number of competent and snitable persons who could be selected in this country to carry out the scheme. It would be better to begin with one wrell selected establishment, sufficient only for one Hospital, than to attempt more than one with more doubtful materials. Much — no one can foresee how much — will depend upon the success of the first attempt. The value of the whole will, in public estimation, be determined by the quality of the first sample that is exhibited. Then the question arises, if there is, at starting, to be only one Hospital nursed, which Hospital ought it to be ? There can be no doubt that it ought to be where it will be under the fostering care of the Governor General. Success at Calcutta would probably carry with it public opinion all over India, and would therefore be of greater value than success anywhere else. But assuming that the Government is satisfied that female nursing ought to be provided for the Hospitals of India, and considering that the Government must be the ultimate judges of success or failure, there is no neces¬ sity or good reason wThy eclat should be desired ; and, on the other hand, in carrying out such an experiment it is but just and right, seeing how many difficulties must in any circumstances be encountered, that it should be tried in the circumstances most favour¬ able to success. If it succeeds, the experience acquired there will enable you to extend it, under less favourable circumstances, with a better prospect of success. In beginning new things we commence with the easier, and having mastered these, proceed to the more difficult. But this is a question the ultimate decision of which must rest with the Governor General. 3 On a consideration of the whole circumstances, then, it appears that there are two things which may be set about immediately. First, — to put in operation means of training Matrons and Head Nurses for service in the general Hospitals and the civil and female Hospitals of India, to be employed on such terms and under such conditions as the Government of India may be disposed or induced to offer. Second, — to find a Matron fitted to be the leading pioneer in such a field, and to provide her with a well selected staff of Head Nurses and Nurses capable of showing what nursing really is, to be employed in such Hospital as the Governor General may determine after due con¬ sideration. Whatever aid I can give in obtaining suitable Matrons and Nurses shall gladly be given. The exclusion of all interference with the department of Nurses, so far as relates to discipline, as herein-after stated, is obviously indispensable. The Regulations given in the Appendix may, with trifling modifications, be adopted for India. If suitable persons can be found, Matrons and Nurses for more than one Hospital might be sent out, and the Governor General would determine to what Hospitals the different Matrons, with their respective establishments, should be sent. If several matrons, with nursing establishments, are sent out, then a General Superin¬ tendent of Nurses should go out at the same time, so that she may hold the reins from the moment of starting. Looking to the extent and population of the Bengal Presidency (including therein the Upper Provinces and the Punjaub), and to the presence of the Governor General, it might be expedient that the three or four Matrons and establish¬ ments first formed should be employed there under a General Superintendent for that Presidency. Madras and Bombay could wait for a time. In case you may consider it advisable to train Nurses in India, I have, in the following suggestions, given such an account of our method of training in England as might enable you to organize a system of training in India. % ' ; J, vs /Vav Wcl NtZLL > { CatfU. inrtlt 'L 4^4, 44 rn A 2 4 SUGGESTIONS. 1. The evidence obtained by the Royal Commission on the Sanitary State of the Indian Army and the information contained in the Minute No. 151 of the Sanitary Commission for Bengal show that the systematic introduction of female nursing into Civil, Military General, and Regimental Female Hospitals would be of great service for the sick in India. 2. The evidence shows that the class of women hitherto employed in this work has been of a comparatively humble character, and without due training, while the nursing has been at the same time highly appreciated by the sick. 3. The desirableness of introducing an organized system of nursing is certainly un¬ doubted, and it cannot but excite great satisfaction that the Governor- General in Council has decided that this improvement shall take place. 4. At the beginning of so important a measure, it is to be feared that nothing but difficulties have to be encountered. But there is no reason why these should not be eventually overcome. It is necessary to state this at the commencement, lest any apparent want of success at first should lead to discontinuance of effort. 5. So far as can be seen the difficulties in India will be of the same kind as, but greater in degree, than those we have had to encounter at home. We have had to introduce an entirely new system, to which the older systems of nursing bear but slight resemblance. Our constant feeling has been that the need is universal and that our means are limited, mainly because the study and practice of nursing as a profession, second only in importance to medicine itself, dates only a few years back in England. It exists neither in Scotland nor in Ireland at the present time. And we, out of our limited means, have to supply a trained Nurse or Matron here and there, in the hope that each may become a centre of improvement, however small, until the growing conviction of the importance of the vast field of usefulness which we have opened for women shall supply us with agents sufficient in number and of such character as will enable us to meet the all but overwhelming demands for help which we receive from all quarters. 6. It will be seen that our means of assisting India directly are at present very limited ; and yet we are most anxious to send some seed. Good nursing does not grow of itself ; it is the result of study, teaching, training, practice, ending in sound tradition which can be transferred elsewhere. 7. The great difficulty to begin with is obtaining suitable material for. training. Even in England, where there is such a constant outcry of want of women’s work, com¬ paratively few apply even as candidates for instruction, although we pay all the costs of training, including payments in the name of wages to Probationers. Of those admitted for training, a proportion are found on trial to be unfit. But all our Nurses, to whom we grant certificates, are taken up at once by different Institutions. [We have just sent twelve and a Matron to Liverpool, and are besides training nineteen for Manchester.] And every woman at all competent is at once appointed Matron to a Hospital. It is necessary that at the very beginning the difficulties which have to be met in organizing a system of nursing for India should be known. It is taken for granted that the difficulties in India, to say the very least of it, will not be fewer than ours at home. 8. Supposing, for the sake of argument, that you have the means of training, viz., a capable Matron, Medical Officers willing to help, and suitable material, probably you could not do better than frame your procedure upon a model which has hitherto been found to answer very well, viz., the Rules for admission and training Nurses at St. 5 Thomas’s and King’s College* Hospitals, London, under the “ Nightingale Fund.” The Probationer Nurses at St. Thomas’s are trained in general nursing duties ; those at King’s College Hospital specially in midwifery and midwifery nursing. In the process of training, the following are the steps : — A. Every woman applying for admission is required to fill up the Form of Application No. l,f which is supplied to her by the Matron of St. Thomas’s Hospital, on application. B. No. 2J are the Regulations under which the Probationer is admitted to training. X * The nursing of King’s College Hospital is carried on by the Society of St. John’s House, which is a Protestant Religious House, a sisterhood having for its main object the care and nursing of the sick in hos¬ pitals, among the poor in their own dwellings, and in private families of the higher classes, besides the training and education of Nurses for this Avork. The sisters are gentlewomen, trained (for two years or more) in all that relates to the nursing of the sick, the routine management of hospitals, wards, &c. Some of these sisters have charge of wards in hospital, and the training and instruction of Probationers, the oversight and direction of Nurses, &c., both in Avards and Avhen off duty. Each sister has definite duty, either in Avards or teaching Probationers othenvise, attending the sick poor, or control of housekeeping matters, and oversight of domestic servants — the system being to guide and encourage those engaged in the paid labour of the Society by the aid of others (the sisters) who are unpaid, more intelligent, educated, with a view to raising the whole tone and character of the nursing attendants of the sick. Each Probationer passes one year in special training for her future duties, by instruction in the manual Avork of a Nurse, attending classes for various instruction by sisters, lectures given by the medical men on physiology, &c., &c., before ranking as Nurse, being then drafted off for either hospital work, nursing in private families, or among the poor, but continuing in the service of St. John’s House. f No. 1. Form to be filled up by Persons applying for Admission as Probationers. Name. Age. Place of Birtli. Where educated. Previous Occupation. AVheiher Single or Married, orAVidow.* If Married, or a AVidow, whether with Chil¬ dren, and if so, with how many. References. * The Marriage Certificate -will be required. I declare the above Statements to be correct, Signature } No. 2. Regulations as to the Training of Probationer Nurses under the Nightingale Fund. 1. The Committee of the Nightingale Fund have made arrangements with the authorities of St. Thomas’s Hospital for giving a year’s training to Avomen desirous of Avorking as Hospital Nurses. 2. Women desirous of receiving this course of training should apply to Mrs. Wardroper, the Matron, at St. Thomas’s Hospital, subject to whose selection they Avill be received into the Hospital as Probationers. The age considered desirable for Probationers is from 25 to 35 ; a certificate of age and a testimonial of character, according to a form which will be supplied by Mrs. Wardroper, Avill be required, also the name and address of Medical Attendant. 3. The Probationers will be under the authority of the Matron of the Hospital, and will be subject to the rules of the Hospital. 4. They will be supplied at the cost of the Nightingale Fund, with separate lodging in the Hospital and with board, including tea and sugar, and with their washing ; and they Avill be furnished Avith a certain quantity of outer clothing, of an uniform character, which they will ahvays be required to wear Avhen in the Hospital. They will serve as Assistant-Nurses in the wards of the Hospital. 5. They will receive instruction from the Sisters and the Resident Medical Officer. They will be paid, at the end of the 1st quarter, a sum of 21.; at the end of the 2nd quarter, 21. 10s.; at the end of the 3rd quarter, 21. 10s.; and at the end of the 4th quarter, 3 1. 6. At the close of a year, their training will be considered complete, and they will he expected to enter into service as Hospital Nurses in such situations as may he offered to them. 7. The names of the Probationers will be entered in a Register, in Avliich a record will be kept of their con¬ duct and qualifications. This will be submitted at the end of every month to the Committee of the Nightingale Fund. At the end of a year those whom the Committee find to have passed satisfactorily through the course of instruction and training will be entered in the Register as certificated Nurses, and will be recommended for employment accordingly. 8. The term of a Probationer’s service is a complete year, and they Avill be received on the distinct under¬ standing that they will remain for that length of time. They may, hoAvever, be allowed to withdraw upon grounds to be appro\'ed by the Committee, upon three months’ notice. They Avill be subject to be discharged at any time by the Matron, in case of misconduct, or should she consider them inefficient or negligent of their duties. They will be eligible, upon proof of competency, during their year of training, or at its close, to permanent appointments as extra Nurses in St. Thomas’s Hospital. The Committee look forAvard with confidence to being able to find situations for their certificated Nurses, either in St. Thomas’s or some other Hospital. 9. The Committee Avill alloAv gratuities of 51. and SI., according to two classes of efficiency, to all their certificated Nurses, on receiving evidence of their having served satisfactorily in a Hospital during one entire year, succeeding that of their training. The first quarter in each year will commence on the 24th June. Applications should be made to Mrs. Wardroper, St. Thomas’s Hospital , London, S., — if personally, between 10 and 11 a.m. A3 ^ on, GJC . rWv\/.f \JUu t- ClsCS h V c #- V G After being received on a month’s trial and trained for a month, if the woman shows sufficient aptitude and character, and is herself desirous to complete her training, she is required to come under the subjoined obligation,* which is printed on the back of No. 2, binding her to enter into Hospital service for at least five years. This is the only recompense the Committee exact for the costs and advantages of training. The list of “ Duties,” No. 3,f is put into the hands of every Probationer on entering the service, as a general instruction for her guidance, and she is checked off by the Matron and “Sisters” (Head Nurses) in these same duties, as will be mentioned immediately. No. 4J is the Day and Night Time Table, to which all Probationers are required generally to conform. It prescribes the time of rising, the ward hours, time of meals, time of exercise, hours- of rest. * Obligation. At the expiration of one month from the date of entry , every Probationer will be required to write a letter to the following effect :• — To the Chairman of the Committee of the Nightingale Fund. Sir, Having now become practically acquainted with the duties required of an Hospital Nurse, I am satis¬ fied that I shall be able and willing, on the completion of my year’s training, to enter into service in a public Hospital or Infirmary, and I promise to continue in such service for the space of at least five years, in whatever situations the Committee shall think suitable to my abilities, it being my intention from henceforth to devote myself to Hospital employment. I am, Sir, Your obedient Servant. t No. 3. Duties of Probationer under the “ Nightingale Fund.” You are required to be Sober. Honest. Truthful. Trustworthy. Punctual. Quiet and Orderly. Cleanly and Neat. You are expected to become skilful — 1. In the dressing of blisters, burns, sores, wounds, and in applying fomentations, poultices, and minor dressings. 2. In the application of leeches, externally and internally. 3. In the administration of enemas for men and women. 4. In the management of trusses, and appliances in uterine complaints. 5. In the best method of friction to the body and extremities. 6. In the management of helpless patients, i.e., moving, changing, personal cleanliness of, feeding, keeping warm, (or cool,) preventing and dressing bed sores, managing position of. 7. In bandaging, making bandages, and rollers, lining of splints, &c. 8. In making the beds of the patients, and removal of sheets whilst patient is in bed. 9. You are required to attend at operations. 10. To be competent to cook gruel, arrowroot, egg flip, puddings, drinks, for the sick. 11. To understand ventilation, or keeping the ward fresh by night as well as by day; you are to be careful that great cleanliness is observed in all the utensils ; those used for the secretions as well as those required for cooking. 12. To make strict observation of the sick in the following particulars : — The state of secretions, expectoration, pulse, skin, appetite ; intelligence, as delirium or stupor ; breathing, sleep, state of wounds, eruptions, formation of matter, effect of diet, or of stimulants, and of medicines. 13. And to learn the management of convalescents. t No. 4. Time Table for the Probationers under the “ Nightingale Fund.” DAY. Rise. Breakfast. Wards. Dinner. Wards. Exercise. Tea. Wards. Dormitory. Supper. Bed. 6 a.m. 6^- a.m. 7 a.m. 1 p.m. 2 p.m. 3^ to 5 p.m. 5 p.m. 6 p.m. 81 p.m. 9.p.m. 10 p.m. NIGHT. Rise. Tea. Wards. Dormitory Breakfast. Wards. Dormitory. Exercise. Dinner. Bed. 9 p.m. 9^ p.m. 10 p.m. 6 a.m. 6-| a.m. 7 a.m. 10 a.m. 11 a.m. to 1 p.m. 1 p.m. 2 p.m. During the Week, Prayers are read in the Wards at 8 a.m., and in the Dormitory at £ before 10 p.m. On Sunday the Probationers are expected to attend Divine Service in the Parish Church, at 11 a.m. By Order, 7 C. From the nature of Midwifery training, it is not practicable to exact the same system at King’s College Hospital Midwifery ward as in the regulated wards of St. Thomas’s Hospital. The class of duties required of Midwifery Nurses is also different. These Nurses are chiefly intended for parish work, and are taken up by parochial committees. They are required, in concert with the parochial or other committee sending them for training, to sign the Agreement No. 5,* which it will be seen does not restrict them to Hospital practice. It will be seen, from the tenor of the agreement, that committees sending Midwifery Nurses for training pay the cost of maintenance, but all other costs of training are paid out of the ‘“Fund.” D. The conditions under which Midwifery Probationers are received at King’s College Hospital are as under.f * No. 5. Agreement made this day of 186 , between herein called the Managers, of the one part, and (the Nurse), of the other part. The Committee of the Nightingale Fund having, at the request of the above-named Managers, agreed to admit the above-named (Nurse), to be trained in the duties of a Midwifery Nurse at King’s College Hospital under the regulations of the Nightingale Fund, and the Managers having provided the means of paying for her maintenance while under training : Now it is mutually agreed as follows, that is to say, the Managers on their part, agree : — That in case the said (Nurse) shall satisfactorily complete her training, they will pay or make up to her a salary or earnings of pounds a year, payable weekly, to commence from the time she leaves the Hospital, and to continue for five years if and so long as she shall on her part comply with the terms of this Agreement, and conduct herself to their satisfaction, and further, that she shall be entitled to any sums of money in excess of the annual sum above mentioned, which under the Rules to be laid down by the Managers, shall be received for her services. The said (Nurse) on her part agrees : — 1. That she will, while under training, readily and cheerfully obey all the Rules to which the Midwifery Nurses may be subject. 2. That after her training is completed, she will for the space of five years from the completion thereof, exclusively employ herself, under the direction of the Managers, in attending such cases of Confinements and other cases of Sickness as the Managers shall select among the poor of and the immediate neighbourhood. 3. That she will not take any money or other return for her services without the permission of the Managers, and that she will in all respects be strictly obedient to such Rules for her conduct and employment as shall from time to time be fixed by them. 4. That if she give up her engagement, or marry, or voluntarily do anything which shall prevent or interfere with the proper discharge of her duties, she will repay to the Managers, by way of penalty, the sum of 50/. less 51. for every complete year during which she shall have been employed, such sum to be recover¬ able as liquidated damages. t No. 6. 1. The Committee of the Nightingale Fund have made arrangements with the Council of St. John’s House, under whose management the “Nursing” in King’s College Hospital is placed, for training annually a limited number of women in the duties of Midwifery Nurses, with a view to their being employed in country parishes or districts, (for the benefit of the poor,) under the direction of the clergy and medical men. 2. The instruction will be gratuitous. In order to accomplish this object, the Committee have engaged to maintain, at the expense of the Fund, a certain number of beds for the reception of poor married women during their confinement, in wards set apart by the Committee of King’s College Hospital for this special purpose ; and the authorities of St. John’s House have agreed to undertake the conduct of the requisite training under the direction of the Physician Accoucheur of the Hospital and the Assistant Physicians for the diseases of women and children. The Nurses will be instructed by an experienced midwife, provided at the cost of the Fund. They will, while under training, attend also certain cases of women confined at their own homes. 3. The period of training will be not less than six months, and the Probationers must undertake to remain at least that time. 4. The cost of board, lodging, and washing to each Probationer for the whole six months will be 10/., paid in advance. 5. The age considered desirable for the Probationers is from 26 to 34. A certificate of health, with the name and address of medical attendant, and strict references as to character, will be required. 6. A record will be kept of the conduct and qualifications of each Probationer. Those who have passed satisfactorily through the course of instruction will be entered in a Register as certificated midwifery Nurses, and a copy of such entry will be sent to those persons who may have recommended the Nurse for the required training. 7. The Probationers will while under training be under the authority of the Lady Superintendent of St. John’s House, and in all*respects subject to the same rules as the regular inmates of the Institution. They will be liable to immediate dismissal by her in case of misconduct, or negligence of their duties ; if she should consider them inefficient, notice, in order to removal, will be sent to the Probationer’s referees, and in neither case will the Probationer be entitled to receive hack any part of the money paid for her maintenance. 8. Probationers will be received on October 31st and April 30th in each year. Application should be made, at least a fortnight previously, to the Lady Superintendent of St. John’s House, King’s College Hospital, London, W.C. 1«/ October 1861. A 4 8 E. Once admitted to St. Thomas’s Hospital, the Probationer is placed under a Head Nurse (Ward “ Sister”) having charge of a ward. In addition to her salary received from the Hospital, the Ward “ Sister ” is paid by the fund for training these Probationers. The number of Probationers she can adequately train of course depends on the size and arrangement of her ward and its number of beds. The Ward “ Sisters” are all under an able Matron, Mrs. Wardroper, who superintends the training of the Probationers, in addition to her other duties, for which the “Fund” pays her 100/. a year, irrespective of her salary as Matron to St. Thomas’s Hospital. The ward training of the Probationers is thus carried out under the Ward “ Sisters” and Matron. To ensure efficiency, each Ward “ Sister ” is supplied with a Book in the Form No. 7,* which corresponds generally with the List of Duties, No. 3, given to the Probationer on her entrance. The columns in the Ward “ Sister’s ” Book are filled up by suitable marks once a week. F. Besides the ward training properly so called, there are a number of duties of a medical and surgical character, in which the Probationers have to be practically instructed. And this instruction is given by the Resident Medical Officer at the bedside or other¬ wise, for which he is remunerated by the “ Fund” at the rate of 50/. a year, indepen¬ dently, of course, of his salary as Permanent Medical Officer of the Hospital. G. St. Thomas’s Hospital is the seat of a well-known Medical School, several of the Professors attached to which, voluntarily and without remuneration, give lectures to the Probationers on subjects connected with their special duties, such as elementary instruction in Chemistry, with reference to air, water, food, &c. ; Physiology, with reference to a knowledge of the leading functions of the body, and general instruction on medical and surgical topics. H. At King’s College Hospital these instructions are given in midwifery and matters connected with the diseases of women and children, during the time of the special training in midwifery. I. While the Ward “ Sisters ” are required to keep a weekly record of the progress of the “ Probationers,” the Probationers themselves are required to keep a diary of their ward wTork, in which they write day by day an account of their duties. They are also required to record special cases of disease, injury, or operation, with the daily changes in the case, and the daily alterations in management, such as a Nurse requires to know. Besides these books, each Nurse keeps notes of the lectures. All these records kept by the Probationers are carefully examined, and are found to afford important indications of the capabilities of the Probationer. * No. 7. Name of Probationer GENERAL REMARKS. Section Date 186 Nature of Duty Punctuality ... Quietness - Trustworthy . - - Personal neat and clean Ward management Dressings - Leeching, external and internal Enemas, M. and F. Trusses ... Uterine appliances Rubbing ... Helpless patients Bandaging - Making ditto ... Making beds - Waiting on operations Sick cooking ... Keeping wards fresh - Cleanliness of utensils Management of convalescents - Observations on the sick V 9 To show the advantage of this, it has happened that some of the worst educated women have shown a far higher aptitude for nursing than those whose writing and composition evinced their education. K. A Register, No. 8 (Appendix), is kept by the Matron of St. Thomas’s. It will he seen that it corresponds with the Ward Sister’s Book, No. 7> and has space for monthly entries during the entire year of training. L. At the end of the year all the documents are carefully examined by the Com¬ mittee of the “ Nightingale Fund,” and the character the Nurse receives is made to correspond as nearly as may be with the results of the training. We do not give the women a printed certificate, but simply enter the names of all certificated Nurses in the Register as such. This was done to prevent them, in the event of misconduct, from using their certificates improperly. When a Nurse has satisfac¬ torily earned the gratuity attached to her certificate, the Committee, through the Secretary, communicate with her and forward the money. 9. This system, which has succeeded with us, would apparently, if it were possible to transplant it, work equally well in India. But it is to be feared that this would be difficult at the present time. The elements required for working such a system of training are : — a. A good General Hospital. b . A competent Training Matron (by such a Matron we do not mean a woman whose business is limited to looking after the linen and housekeeping of the Hospital, either wholly or mostly, but a woman who, whatever may be her duties as Head of the Establishment, performs chiefly and above all others the duty of superintending the nursing of the sick). If in India it is the custom for the Matron to be simply housekeeper, then there must be a separate Training and Nursing Matron (as we are about to establish in one of the largest workhouse infirmaries in the kingdom), and competent to train. The number she could train would depend entirely on the construction of the Hospital, and on the capabilities of the “ Head Nurses” or “Ward Sisters” under her. c. Competent “ Head Nurses.” If such are or can be appointed, they should be responsible to the Training Matron ; and the Training Matron is not to be responsible in any case to the Housekeeping Matron, [it would, of course, be better that there should be but one Matron, with a Housekeeper subordinate to her.] The Head Nurses must be competent trainers. Each might perhaps train four Proba¬ tioners in a properly constructed ward. Of course the Training Matron, if she is to be herself her only Head Nurse, can only train such a number of Probationers as a Head Nurse could train. Our period of training is one year for a Nurse, twTo years for a Head Nurse. The Training and Nursing Matron should be responsible to the Civil or Military authorities, as the case may be, or to any Committee appointed by them for the purpose. It has occurred to all that you might find General Hospital accommodation for your principal training establishments at Calcutta, Bombay, and Madras ;* but in the existing deficiency of materials for training, if all three localities cannot be undertaken, it would be better to confine your attention to Calcutta, to do the work well there, and then to distribute Trained Nurses as Head Nurses to train others. 10. It is taken for granted that the Medical Officers of Hospitals where training is to be carried on are willing in India, as elsewhere, to render every assistance in their power in aiding the training by oral instruction and bedside work. 1 1 . All Nurses, after training, might be certificated by the Governing Body, in the manner mentioned. The subjects of training, and the method of record, would apparently be the same in India as here. 12. Sufficient has been said on the subject of training to show that the success of any system must primarily depend upon your obtaining one or more Trained Nurses, themselves capable of training others. So far as information has been given, you have no one in India at the present time competent for this work. If it should so happen that we could not send you a good Training Matron, your best way would be to select the most competent woman you have, and act under our method. But at the best this would be simply a shade better than nothing. * There used to be a system of training Military Female Orphans for Nurses, at the Asylum at Madras under Dr. Macpherson. But no recent information has been received here about it. 11623. B 10 We are so impressed with this, that we have been making inquiries whether we could not help you, even out of our own poverty in agents. We have been very much pleased to find that the proposal of introducing a Nursing system into India has been received at both our Training Establishments with very great interest, and that every one is ready to help to the very utmost. If volunteers were asked for we believe they could be had ; but we have ventured only to raise the question with a view to its being considered by the authorities in India. 13. If you in India should be of opinion that it would be an advantage to have one or two of our Trained Matrons, accompanied by as many Trained Nurses as we can provide, we here will try our best to send them. It would, indeed, be in every way most desirable, if we can accomplish it, to send you a complete staff, with which you could begin your work of Hospital Nursing as well as of Training at any Hospital you may consider best suited for the object. The usual way of obtaining Nurses trained under the “ Nightingale Fund” is to make application to our Training Matron, Mrs. Ward- roper, of St. Thomas’s Hospital, and Miss Jones, Lady Superintendent of King’s College Hospital. If you see fit to enclose any applications to either of these ladies through me, I will do what is requisite. In order to avoid delay, it would be necessary to state what wages and salaries it is proposed to give, and that the travelling expenses would be paid. We might not be able to send Nurses at once, because we always require one year at least of completed training, and we are always behindhand with our engagements. In fact, the demand is very much beyond our power to supply. The question has, however, been raised, and we shall be surprised if, before long, suitable women do not volunteer. We have, as you are aware, a Superintendent- General of Nurses in Military Hospitals, stationed at Netley. One of her duties is training Military Nurses. At present the staff required for home use is incomplete ; and none can be spared for India. But it is possible that eventually English Military General Hospitals may be able to supply a certain number of trained Nurses for India. We, however, always consider it necessary that such Nurses should have had training in a Civil as well as in a Military Hospital before they are appointed. 14. The next point of importance is, supposing you supplied with trained Nurses, in what way to organize a Nursing Establishment for the Military Hospitals of India. a. There must be a Superintendent-General for each Presidency, who must be respon¬ sible, directly or indirectly, to the Government of the Presidency. b. Under this Superintendent-General should be placed all the Nurses of the Presi¬ dency, stationed in Hospitals of whatever class, the expenses of which are either partially or wholly paid by Government. c. The Hospitals into which female Nursing can be most satisfactorily introduced are — Military General Hospitals. Civil „ „ Regimental Female „ d. Wherever there is more than one female Nurse there must be one woman in the position of Matron, and she must, of course, be an European. e. The European Nurses should be selected and sent off by the Superintendent- General of the Presidency. f. These European Nurses would require native assistants; and one of their most important duties would be to train these assistants at the Station. g. It would be most desirable, in the event of any European woman of good character or fair ability presenting herself at any Station, to send her for training to the Training Hospital of the Presidency. Suppose, then, you have obtained your Superintendent- General, your Hospital Matrons (Superintendents of Nurses), and Nurses, the next important question is the one of government. In discussing this point, it is necessary to state whom the Nurses should not be under. They should not be under the Medical Officer for discipline. They should be under no male Officer at any Station, i.e.> from the time the system is in full operation. The Superintendent- General of each Presidency should be head of the discipline over all Superintendents and Nurses in all classes of Hospitals ; and she herself should be responsible solely to the Government of the Presidency, directly or indirectly. The Matrons (Superintendents of Nurses) in Hospitals should be directly under the Superintendent- General. 11 In like manner, the Nurses in each Hospital should be under the Matron ( Superintendent) of the Hospital. i. The duties which each grade has to perform should be laid down by Regulation, and all that the Medical Department or the Governing Body of the Hospital has a right to require is that the Regulation duties shall be faithfully performed. Any remissness or neglect of duty is a breach of discipline as well as drunkenness or other bad conduct, and can only be dealt with to any good purpose by report to the Matron ( Superintendent of Nurses) of the Hospital, and, failing her, to the Superin¬ tendent-General of the Presidency. It is necessary to dwell strongly on this point, because there has been not unfre- quently a disposition shown to make the Nursing Establishment responsible on the side of discipline to the Medical Officer, or to the Civil or Military Governor of the Hospital. Any attempt to introduce such a system in India would be merely to try anew and to fail anew in an attempt which has frequently been made in Europe. In disciplinary matters, a woman only can understand a woman. It is the duty of the Medical Officer to give what orders, in regard to the sick, he thinks fit to the Nurses. And it is unquestionably the duty of the Nurses to obey or to see his orders carried out. Simplicity of rules, placing the Nurses in all matters regarding management of siek absolutely under the orders of the Medical men, and in all disciplinary matters absolutely under the female Superintendent, to whom the Medical Officers should report all cases of neglect, is very important. At the outset there must be a clear and recorded definition of the limits of these two classes of jurisdiction. But neither the Medical Officer nor any other male head should ever have power to punish for disobedience. His duty should end with reporting the case to the female Superior. k. The duties to be discharged by the Superintendent-General, Superintendents (Matrons), and by Nurses, are full}' laid down in the Regulations for General Hospitals, and in the Regulations for Nurses, contained in the new Medical Regulations of the British Army. ( Vide Appendix II.) These Regulations would apparently answer as they are, or nearly as they are, for Military General Hospitals, in which the heavy duties of the wards would have to be performed in India by male Orderlies or by male native attendants acting under the direction of the Nurse. In Regimental Female Hospitals, where there would be no male attendants, it would be necessary to place native female attendants at the disposal of the European Nurse, or Matron, to perform certain classes of ward duties. In Civil Hospitals the male attendants on the male side, and the female attendants on the female side, would have to be placed under the direction of the Trained Nurse or Nurses. The Regulations would have to be altered to this extent ; they would also have to be altered as regards pay, pension, and retirement ; and possibly, in some matters of detail, that can only be settled with reference to local customs and experience. The chief practical point is that, in framing the Regulations for the Nursing Service in Hospitals in India, the British Army Hospital Regulations referred to should be taken as a ground-work, and departed from as little as possible. l. The great difficulty in the way of government is, — what best to do in the interval between beginning Female Nursing and organizing the Nursing of the Presidency under a Superintendent-General. This will especially be the case as regards Female Regimental Hospitals, where the staff will never be more than two, or at most three, trained Nurses, one of whom must be Matron, but still she will not be of the calibre justly demanded for a Superintendent. The least of several evils appears to be some such system as that adopted for Female Regimental Hospitals in England, during the transition time until the Superintendent- General can take charge of all Hospitals appertaining to the army. Wherever there is a Female (Military) Hospital in England, a Ladies’ Committee is appointed at the station. This Committee takes a general charge of the Hospital and Nursing, and the Medical Officer reports to the Committee any complaints against Matron or Nurses, the Ladies’ Committee exercising discipline. That portion of the War Office Regulations for Female Hospitals at home, bearing on the question of discipline, is given in Appendix III. It is possible that some such organization may answer for securing efficiency among Nurses in Regimental Female Hospitals in India, until a complete system is organized under a Superintendent-General. *1623. C 12 15. We are afraid that the rates of pay in England will hot suffice in India, for various obvious reasons. To take Military Hospital Nurses, first Even in England it is found that the pay, beginning at 20/. a year, although it rises by 2/. a year so as to become 30/. per annum after five years’ service, is not enough to secure the class of women necessary for this kind of service ; and the Secretary of State for War has been obliged to raise it to 30/. a year for the first year. These Nurses, of course, receive board, lodging, and an uniform dress, besides pay and pension. The present Superintendent- General here serves without pay ; but this must be always an exceptional case. As to Superintendents’ and Matrons’ pay : — The largest Civil Hospital in London gives 200/. a year and a house. The others give 150/. and a house, coals, and beer; sometimes a maid, sometimes other privileges. The Training Matron at St. Thomas’s Hospital receives altogether 250/. a year, a house, coals, beer, and other privileges.. Even in England, for any good Training Matron, 200/. a year, quarters, and a maid, is not at all too much. In our large Civil Hospitals, the Head Nurses receive 50/. or 60/., or even 70/. per annum, with firing, milk, beer, and light, and many other such privileges ; besides one or two rooms, and sometimes a pension. A good Training Head Nurse is worth her weight in gold. She cannot be easily replaced. This rate of pay is not at all too high, even in England. What it must be in India, where the opportunity of marriage for every decent woman is so much greater, you will be better able to judge. To meet this contingency, it may be necessary, in obtaining Nurses from England, that some agreement as to service should be entered into, in order that all the trouble and cost of having them out should not be lost by their marrying directly they are out. A similar risk of loss of service, though not of travelling expenses, would apply to Nurses trained in India. It is hardly necessary to add that no women but of unblemished character can ever be admitted as Nurses. Hospitals are the worst places to employ penitents in. In conclusion I would recommend as follows : — 1. If you have a first-rate Nurse of sufficient experience (such a woman as would be accepted as a Matron in a large London Hospital) who could act as Training Matron, place her in a suitable Hospital, obtain for her the best European material for training which may be available on the spot, and let her train as nearly as may be in con¬ formity with the plan described above. 2. If you have no Matron on whom you can rely for training, we here will try to send you one or more, and also as many Trained Nurses as we from time to time may be able to spare, on receiving application in the manner already mentioned, stating salary, &c. If you receive a Nursing Staff with its Matron from England, it will be better to place it complete at the Hospital you may select, so that you may have an example of efficient nursing, as well as a Training School for Nurses. 3. The best manner of extending the system of nursing with Nurses trained in India will be to place a Matron and two Nurses at least at each of the larger Hospitals, there to nurse the sick and to train other Nurses, European or native. But the more complete you can make the Nursing Staff for any new Hospital at the beginning, the greater will be your chance of success. 4. Whatever interim method of government you may find it necessary to adopt for your nursing establishment, you should, as soon as circumstances admit, organize a system of nursing for each Presidency under a Superintendent-General, a Matron (Superintendent of Nurses) for each Hospital, and Hospital Nurses. 5. The Regulations under which the various duties of these Officers are to be performed, should be based on and approximate as nearly as possible to the Regulations for Nurses in Her Majesty’s Hospitals, already mentioned. Florence Nightingale. London, February 24, 1865. 13 f > / H-i XI - 5 £ w ph 00 d X; X o >— 1 Eh <5 M O P3 Ph O X i— i 3 Q S3 W H O <5 PC <1 a o IJ <1 PC O S w H B 0 H o M H H H H H 3 n o 02 §> Q «C .© <{3* co 3 ^ ° S s ‘c © P b s** i © a Co V' co ^3 CO SJ •Si !?■ Si ■1 • £ .© •c © 5 *§ C 2 If defective, state nature of defect in this line. f State in this line any duty in the columns in which the Nurse is prominently excellent (E.) or imperfect (I.) 14 APPENDIX II. "Regulations affecting the Duties of Superintendents- General, Superintendents, and Nurses in British Military Hospitals. Section VHI _ Orderly to obey Directions of Nurse. 46. The Orderly shall conform strictly to the requirements of the Nurses, and shall obey them in all matters contained in the regulations for Nurses. Section VHI. — Nursing in General Hospitals. Superintendent- General of Nurses. 50. A Superintendent-General of Nurses, specially selected for her personal qualifications for the office, appointed by the Secretary of State for War, and removable by him, will be at the head of all Superintendents and Nurses in all General Hos¬ pitals, where there are Nurses, at home and abroad, in peace and in war. To enforce Discipline. 51. It will be her special duty to enforce necessary discipline among all Superintendents and Nurses, so that the orders of the Medical Officers in matters relating to the comfort and care of the sick may be efficiently carried out. Communication with Secretary of State and Director- General. 52. Her appointment will be notified in General Orders, and she will have the power of communicating directly with the Secretary of State for War. The Director-General will communicate directly with her on any change he may desire to have introduced in the arrangements, having for their object the nursing of the sick in General Hospitals ; and it will be her duty, in combination with her other duties, to make such arrangements as shall give the Director- General satisfaction. In the event of any difference of opinion between the Director-General and the Superintendent-General, the matter shall be decided by reference to the Secretary of State for War. One Superintendent for each General Hospital where there are Nurses. 53. The Superintendent- General of Nurses shall choose and appoint a Superintendent in every General Hospital where there are Nurses, as Head over the Nurses in the Hospital. She shall have an Assistant, ranking and paid as a Nurse, to take charge under her of the linen, who is to have nothing to do in the wards. No Superintendent shall be appointed to or removed from any General Hospital without the Superintendent-General’s sanction, and all appoint¬ ments or removals of Superintendents made by her must be notified to the Director-General. Nurses not to exceed One for Twenty-five Sick. 54. The Superintendent-General of Nurses shall choose and appoint Nurses for each General Hospital, on requisition of the Director-General, in such pro¬ portion that no Nurse shall have charge of fewer than twenty-five cases. No Nurse shall be appointed to, or removed from, any General Hospital without her sanction ; and all appointments or removals of Nurses made by her must be notified to the Director- General. Duties of Superintendent ■ General , Superintendents, and Nurses. 55. The respective duties and responsibilities of the Superintendent-General, Superintendents, and Nurses are laid down in the Regulations. Ward Medical Officer to give Directions to Nurse. 56. The Staff Surgeon or prescribing Medical Officer, as the case may be, in any General Hospital where there are Nurses, shall require the Nurse to attend him in his visits, and shall deliver to her his orders with reference to the sick. But when he considers that any change of arrangements of duty is desirable, he shall communicate on the subject directly with the Superintendent. Medical Officer to report Neglect of Duty of Nurse immediately to Superintendent. 57. The Medical Officer must report immediately to the Superintendent any neglect of duty or misconduct on the part of the Nurse, in order that the necessary steps may be taken thereon by the Superintendent. Principal Medical Officer to communicate directly with Superintendent. 58. The Principal Medical Officer in each General Hospital where there are Nurses shall communicate directly with the Superintendent on any change of arrangements he may consider desir able in the nursing of the sick ; and it will be the Superintendent’s duty, in combination with her other duties, to make such arrangements as shall give the Principal Medical Officer satisfaction. REGULATIONS FOR NURSES. Duties of Superintendent-General. To appoint Superintendents of Nurses ; one to each Hospital. 1. The Superintendent- General of Nurses shall, on requisition of the Director-General, select and appoint all Superintendents of Nurses and Nurses for General Hospitals. She shall place one Superintendent over each Hospital where there are Nurses. Power of transferring Superintendents and Nurses. 2. She shall have the power of transferring Super¬ intendents and Nurses from one Hospital to another, whether at home or abroad, in peace or in war. Duties of Superintendent- General during War. 3. When General Hospitals are formed during war, the Superintendent-General, or some person specially appointed by her for the purpose, shall, when required by the Secretary of State for War, proceed to the spot, and, in communication with the Governor and Principal Medical Officer, shall undertake the super¬ intendence of all Superintendents and Nurses, and shall exercise all the powers vested in the Superin¬ tendent-General by the regulations. To visit and place Nurses in New Hospitals. 4. When a Superintendent and Nurses are to be provided for any General Hospital, the Superin¬ tendent-General, or some person appointed by her specially for the duty, shall visit the same, make herself acquainted with the arrangement of the wards and Nurses’ quarters, and shall place the staff of Nurses, together with the Superintendent of Nurses, to the satisfaction of the Principal Medical Officer, and explain to them the nature of their duties, and any special points requiring to be attended to in the Hospital arrangements. She shall be entitled to quarters and rations or mess money in whatever Hospital she may be for the time. She may suspend or dismiss Superintendents. 5. The Superintendent-General may suspend or dismiss any Superintendent for breach of discipline or misconduct, subject to power of appeal on the part of the Superintendent to the Secretary of State for War. 15 She may give Directions to Superintendents. 6. She may give any directions or instructions for the guidance of Superintendents of Nurses in the dis¬ charge of their duties, provided such directions or instructions are not inconsistent with these regu¬ lations. To decide on Appeals from Nurses. 7. She shall receive and decide on all appeals made to her by Nurses against the decision of the Super¬ intendent. To make up Annual Estimates. 8. She shall make up annual estimates of the cost of the Nursing Establishment in every Hospital, and transmit the same to the Secretary of State for War. To pay Salaries and Wages. 9. All salaries, wages, and mess money of Super¬ intendents of Nurses and Nurses shall be paid on her order from the Hospital chest, to the Superin¬ tendent of Nurses, who shall pay the wages and other expenses of the Nurses, and account for all monies received by her on such orders. All outfits, and travelling expenses in cases of transfer of Superin¬ tendents and Nurses from one Hospital to another, shall be provided on the order of the Superintendent- General. To keep Books and Accounts. 10. She shall keep the books and accounts con¬ nected with the whole Nursing Staff of General Hospitals. To make up Abstracts of Rations. 11. She shall make up periodically an abstract of the monthly abstracts of rations, received by her from the Superintendents of Nurses of all the Hospitals, and transmit the same periodically to the Secretary of State for War. To make Visits of Inspection. 12. She shall make visits of inspection at such times as she may consider requisite to ensure that all the Nursing Establishments are in an efficient state, and at the time of such inspections she may appoint a substitute to undertake her duties during her absence, subject to the approval of the Secretary of State for War. To report to Secretary of State for War. 13. She shall report on the state of efficiency of the Nursing in all Hospitals under her charge to the Secretary of State for War, once a year ; and in order to enable her to do this, copies of all reports, confi¬ dential or otherwise, which have been made to the Secretary of State or to the Army Medical Depart¬ ment regarding the Nursing Establishment, will be transmitted to her. Duties of Superintendent of Nurses. Responsible for Nursing. 14. The Superintendent of Nurses is responsible to the Superintendent-General for the efficiency of the Nursing in the Hospital where she is placed. T o allot Duties and watch over Nurses. 15. She shall allot the current duties of her Nurses. She shall keep a constant watch over their moral conduct. She shall see that their dress, cleanliness, and personal habits are properly attended to, and that they are on duty at the prescribed hours. To see Duties properly performed. 16. She shall satisfy herself that all nursing duties are discharged with faithfulness, consideration, and kindness ; and for this purpose she shall visit the wards frequently, and note any negligence or inca¬ pacity ; and in such case, or when she is informed, by the Medical Officer of the ward, of any neglect of duty or impropriety of conduct on the part of a Nurse, she shall privately reprimand the Nurse for the same, c and issue her directions for preventing similar defects in future. May suspend Nurses. 17. She may suspend any Nurse for neglect of duty or misconduct, and provide temporary assist¬ ance ; but in every such case she must notify the fact forthwith to the Governor, and to the Superin¬ tendent-General, stating distinctly the reasons of the suspension, and the qualifications of the assistant. May dismiss Nurses under Appeal. 18. The Superintendent in any Hospital, out of Great Britain and Ireland, with the concurrence of the Governor, may dismiss and send home any Nurse, or the Governor himself, on his own responsibility, may direct the Superintendent to do so, under appeal, however, in either case to the Superintendent- General, who shall decide, after the arrival of the Nurse, whether she is to be dismissed, or whether she may be placed in another Hospital. Disinissal to be under Sanction of Superintendent- General. 19. No Superintendent, in any Hospital in Great Britain or Ireland, shall dismiss or send away a Nurse unless the sanction of the Superintendent- General be previously obtained. Superintendent to pay Nurses. 20. All wages, mess money, or other expenses of the Nurses shall be disbursed through the Superin¬ tendent, on the order of the Superintendent-General. The Superintendent shall receive the necessary sums from the Paymaster, shall pay the wages, mess ac¬ counts, and expenses, and account for the same to the Paymaster, and shall transmit the accounts of such payments, with a duplicate of the requisite vouchers, to the Superintendent-General. Superintendent responsible for linen. 21. She shall be responsible for the storing, mend¬ ing, and distribution of the linen, for which purpose sufficient assistance will be provided by the Gover¬ nor. She should return to the laundry any linen not properly washed or dried, and report the circumstance to the Captain of Orderlies. She shall have an Assistant, ranking and paid as a Nurse, to be called linen Nurse, to take charge, under her, of the linen — the Assistant to have nothing to do in the wards. Superintendent to keep Books and Accounts. 22. The Superintendent shall keep all books, records, and accounts of the Nursing Establishment of the Hospital, and transmit her accounts to the Superintendent-General once a quarter, or oftener if required to do so. Superintendent to draiv Rations. 23. The Superintendent of Nurses in any General Hospital connected with an army in the field, or on any foreign station, where it may appear to the Superintendent-General to be ■ necessary, is em¬ powered to draw from the Purveyor on her own indent, with the sanction of the Governor of the Hospital, such rations and extras as she may consider necessary for hei'self and for the Nursing Establish¬ ment, and shall make arrangements for cooking and for the hours of meals. But in the United Kingdom, and on such foreign stations as the Superintendent- General may decide, mess money in lieu of rations will be allowed for the Superintendent and Nursing Establishment, on representation to that effect being made by the Superintendent-General. The mess money will in such cases be paid to the Superinten¬ dent of Nurses of the Hospital, and disbursed and accounted for by her to the Superintendent-General. To make up Monthly Abstracts of Rations. 24. The Superintendent shall make up monthly abstracts of rations received for the Nursing Esta¬ blishment of the Hospital where she is in charge (if 3 16 rations have been provided), and shall transmit the same to the Superintendent-General of Nurses once a month, or as often as she may be required by the Superintendent-General to do so, and the Supenn- tendent-General, after having satisfied herself re¬ garding the correctness of such abstracts, shall ceitify and transmit the same to the Secretary of State for War. To report on the Efficiency of Nurses. 25. The Superintendent shall report on the effi¬ ciency or otherwise of her Nurses to the Superinten¬ dent-General at such times and in such manner as the latter may appoint. And she shall, moreover, report on every complaint made by a Medical Officer against a Nurse in her next report. Age, Service, and Retirement of Superintendent. 26. The Superintendent shall be, on appointment, not under thirty, nor over forty years of age, and she shall not continue in the service after she has attained the age of sixty years, at which age she shall retire with a pension equal to 50 per cent, of her salary at the time of her retirement. Should the Superintendent be obliged to leave the service on account of disability, certified by two Medical Officers, she shall (provided she has served twelve full years) be entitled to a pension equal to 20 per cent, of her salary at the end of the twelfth year. If she retires from disability at any period after twelve years, and before she arrives at the age of sixty years, her pension shall be 20 per cent, of her salary With the addition of two per cent, of her salary for every full year above twelve years she has served. But in any case she may be called on for service in the event of her disability ceasing, when her pension will be discontinued, and her salary paid as before. Any Superintendent who may be obliged to leave the service from disability, certified by two Medical Officers, provided she retire before the com¬ pletion of twelve full years of service, will receive a gratuity, the 'amount of which will be recommended by the Superintendent-General. Age of Nurses. 27. Except in cases of emergency, no Nurse shall be appointed to any Military General Hospital under thirty or above forty years of age, and no Nurse shall continue in the service after she is sixty years of age. Requirements for Appointment. 28. Every Nurse must be able to write, and must produce satisfactory certificates of former good con¬ duct before she is appointed to any Military Hospital. Wages and Pension. 29. Nurses on entering the service will be allowed wages, with a small annual increase, and on leaving the service a pension, as follows : — At whatever age a Nurse enters the service, the amount of wages paid to her during her first year of service will be 20/. — 2. There will be an annual increase of wages, at the rate of 21. additional every year, until the yearly wages amount to 50/., beyond which there will be no further increase. — 3. Every Nurse who has completed her sixtieth year must retire from the ser¬ vice on her rate of pension. — 4. A pension will be awarded to any Nurse who is declared on the report of two Medical Officers specially appointed for the purpose, and on the report of the Superintendent- General, absolutely unfit for Hospital duty, through disease or injury ; provided that she has been ten complete years in the service. — 5. A Nurse’s pension will be on a scale graduated on the wages. It wfill be 30 per cent, of the wages received by the Nurse in her tenth year of service. And the pension £ranted to Nurses who have served more than ten years will rise at the rate of two per cent, of the wages for every additional year of service, until the pension amounts to 70 per cent, of the wages received during the year preceding its grant, beyond which there will be no rise. — 6. Any Nurse, temporarily or permanently disabled in the service, who has served more than five and under ten years, will be entitled to a lower rate of pension, according to the circum¬ stances of each case ; but if she has served less than five years she shall receive a gratuity according to the circumstances, as reported by the Superintendent- General. — 7. Any Nurse pensioned for disability must present to the Superintendent-General an annual Medical Certificate of the state of her health before she receives her pension, and if called on for service in the event of such disability ceasing, her wages will be the same as they would have been had she not been disabled, or should she decline re-entering the service, her pension will cease. — 8. In any case of special devotion to the public service, the Superinten¬ dent-General may represent the circumstances to the Secretary of State for War, who may recommend that a higher rate of pension than that fixed by regulation may be granted, provided that no such pension shall exceed the annual amount of 50/. — 9. Any Nurse who has received a gratuity for disability incurred under five years of service may be re-engaged in the public service should she apply for re-engagement, and be found fit, and her rate of wages shall count from the rate she received at the period of her retire¬ ment. — 10. Any Nurse serving in a General Hospital in tropical climates will be entitled to count one year as equal to two years of service, for pension, in case of disability. Rations. 30. Nurses shall be allowed rations and extras, to be drawn by the Superintendent. Porter, fyc. 31. Each Nurse will be allowed one pint of porter or ale, and half a pint of porter or a wine-glass of wine, or one ounce of brandy, as she likes best, per diem. In case of constant attendance on cholera or fever patients, the Superintendent may allow an extra quantity, at her discretion. Dress. 32. Nurses will be allowed at the public expense, a badge, and a regulation dress, as follows, which is to be varied according to climate, as the Superin¬ tendent-General may decide, and in which they are always to appear, except on holidays : — Three good dark gowns, six aprons, six caj^s, six collars, one bonnet, annually ; one summer and one winter cloak triennially. They will be allowed clothing for out¬ fit in the event of their going on service out of the country. The amount of such clothing will be deter¬ mined by the Superintendent-General of Nurses. They will also be allowed necessary travelling ex¬ penses, with board, and a fixed amount of transport for baggage, in going abroad, in returning home, and in changing from one Hospital to another. To be given up on Dismissal. 33. Nurses dismissed for misconduct will forfeit the whole of their regulation clothing, which shall be returned to the Superintendent. No Nurse to receive a Present. 34. Any Nurse asking or accepting a present, whether in money or in kind, from any patient or friend of any patient, whether during his illness or after his death, recovery, or departure, shall be at once suspended from duty, and her pay will immedi¬ ately cease, and she will be reported to the Super¬ intendent-General of Nurses, who, if satisfied of the truth of the charge, will immediately dismiss her. Dismissal for Intoxication. 35. If any Nurse be found intoxicated she will be at once suspended from duty, and her pay will immediately cease, and she will be reported to the Superintendent-General of Nurses, who, if satisfied of the truth of the charge, will immediately dismiss 17 her. No Nurse during her suspension shall be permitted to enter any ward of the Hospital. Cannot be re-engaged. 36. No Nurse, discharged for misconduct of any kind, can be engaged again for the Government service, and any Nurse retiring from the service without permission from the Superintendent-General, will forfeit all claim to pension or re-engagement in the public service. Pay to cease on Dismissal for Misconduct. 37. Nurses discharged for misconduct will be paid only to the day of their discharge, and if discharged while on service abroad, will be sent home as third-class passengers. Travelling Expenses on returning Home sick. 38. A Nurse discharged from service on account of ill-health, certified by two Medical Officers, whether she may be in receipt of a pension or a gratuity, will be entitled to board and travelling expenses from the place of her discharge to her own home. Nurses must be generally useful on War Service. 39. When on war service each Nurse, in addition to her customary nursing duties, must (at the dis¬ cretion of the Superintendent) do needlework for the Hospital, cook extras for the sick in the extra diet kitchen, and generally discharge such other household duties as the Superintendent may require. No Nurse is to be permitted to wash her own linen, unless in war service. Lodging to be conveniently situated. 40. The Nurse’s lodging should be conveniently situated for her ward duties, and she shall clean it herself. Hours of Exercise. 41. The hours of exercise or recreation, as well as holidays, will be fixed by the Superintendent, with reference to the ward duties. It is necessary for the health of the Nurse, and for the efficient dis¬ charge of ward duties, that she should take frequent exercise in the fresh air. No Nurse must be out of Hospital before or after the limit of her exercise time without written permission of the Superintendent. Visitors' Days. 42. Nurses shall receive visitors only on such days of the week, and at such hours, as may be specified by the Superintendent. Rest and Recreation. 43. Nurses should have eight hours for sleep, and whenever possible two hours daily for exercise or recreation. One Nurse for each Ward. 44. Every ward or set of wards, except venereal and convalescent wards, according to their size and the number of patients they contain, should be under a Nurse, who is to be responsible for their condition. She shall keep the keys of all store-closets, or lock-up places, which are to be provided in the- ward. Nothing appertaining to the ward is to be kept in the Nurse’s room. Superintendent to appoint Times of Duty. The Nurse shall enter on her ward duties day by day, at such time as the Superintendent may appoint, in conformity with the orders of the Medical Officer, and the instructions of the Superintendent-Genei’al. Duties of Nurses. Nurse to receive and obey Orders of Medical Officer. 45. The Nurse shall always attend the Medical Officer of the ward on his visits, and shall receive and obey all his orders regarding the administration of medicine and medical comforts, the preparation of tea, sago, arrowroot, or beef tea, the administration of food and drink to helpless patients, the application of leeches and blisters, poulticing and minor dressings, the administration of enemas, when required by the Medical Officer to do so, and the due warming and ventilation of the ward. Nurse responsible for Cleanliness of Wards and Obedience of Sick. 46. She shall be responsible for the personal cleanliness of the patient, for the care and cleanliness of his linen, bedding, and utensils, and for his personal obedience to the orders of the Medical Officer, as to keeping his bed or his position, &c. She shall see that the ward, its furniture, and utensils are cleaned, and the helpless patients washed by the Orderlies before the morning visit. To require Orderlies to obey her. 47. To fulfil these responsibilities, the Nurse shall give such instruction to the Orderlies in any of these details as she may consider necessary, and she shall require the Orderlies in her ward to obey her directions in any of these matters ; and in case of neglect or disobedience on the part of any Orderly, or in case of any breach of discipline in a ward, or in case of swearing or use of foul language by any patient or Orderly, she shall report the same to the Superintendent, who shall lay the complaint before the Captain of Orderlies. But in an emergency the Nurse, if she consider it necessary, may report direct to the Captain of Orderlies or to the Medical Officer. To obey Directions of Superintendent. 48. She shall receive any directions the Superin¬ tendent may give in reference to any details of her work, and shall conform to the same. Diets, SfC. to be brought into the Wards. 49. In order to save the time of Nurses, and to prevent breaches of discipline, all diets and ward requisites should be brought into the wards, or a least to the ward doors. Nothing should be fetched by the Nurses. Hours for Medicines , Diets, fyc. to be fixed. 50. The Nurse shall conform to the hours of morning and evening poulticing and minor dressings fixed by the Medical Officer, also to the hours for administra¬ tion of medicine and diets, whether hung up in the ward or written in the ward book. Nurse to administer Medicines, Wine, Spirits, and Malt Liquor. 51. Medicines, wine, spirits, and malt liquor are always to be administered by the Nurse in attendance, in conformity with the orders of the Medical Officer. Unpaid Superintendents and Nurses to obey Regulations. 52. Any Superintendent or Nurse who may receive permission to serve in Her Majesty’s Hospitals with¬ out pay, shall be, in all respects, bound by, and amenable to, these regulations, on pain of dismissal from the service, without permission to re-enter it. 18 APPENDIX III. Regulations for Female Hospitals. XI. The following regulations are to be observed in Female Hospitals, till complete arangements can be made : — 1. At every station where a Female Hospital has been provided, a Committee of Officers may be appointed by the Officer Commanding at the station, who will have charge of the Charitable Fund con¬ nected with the Institution, and will deal with all financial matters connected with it, which may be referred to them. A Committee of Ladies selected by the Committee of Officers will undertake the visitation of the Hospital, and the management of extra clothing supplied by the charitable fund. They will inquire into cases of distress brought to their notice, and will make thereon such suggestions to the Committee of Officers as may seem to them to be necessary. The Ladies’ Committee may appoint a Sub-Com¬ mittee of not fewer than three to perform the duties lierein-after mentioned. 2. The Medical Officer attached to the Hospital will take charge of all cases of sickness admitted therein, and also of lying-in women and their infants. He will prescribe Medicines for them from the Surgery Stores, and order Diets and Medical Com¬ forts from the Purveyor’s Stores (in conformity with existing Regulations as to Hospital Diets and extras). The scale of Hospital Diets will be that prescribed at page 60 of the Medical Regulations ; in addition to which the following extras will be allowed : — Wines, spirits, malt liquors, arrowroot, sago, eggs, milk, tea, sugar, beef tea or essence of beef', oranges and lemons ; 4 oz. of oatmeal and 8 oz. of milk may also be issued on Spoon Diet, in lieu of 2 oz. arrow- root and 1 oz. sugar. The cases for which extras are prescribed must be invariably entered in the Medical Case Book by the Medical Officer, tvho will otherwise be held responsible for the cost of the issues. 3. The Purveyor will furnish female wards with the usual ward equipments ; he will see that the bed and body linen of the patients is properly washed, and that the wards are warmed and lighted to the satisfaction of the Medical Officer. 4. The Purveyor will discharge the same duties as to repairs in Female Hospitals as he does in Military Hospitals generally. 5. The Medical Officer is charged with the dis¬ cipline over the patients in hospital. 6. A Matron (who should, if possible, be competent to act as midwife), and one or more female nurses, will be allowed to each Hospital, on the requisition of the Principal Medical Officer, made through the Officer Commanding to the Secretary of State for War, and will be appointed in the following manner : — 7. All applications and testimonials respecting candidates for the office of Matron (who should be unmarried or a widow) will be transmitted through the Officer Commanding to the War Office by the Ladies’ Committee, who will make the necessary inquiries as to character and ability, and report the result through the same channel to the Secretary of State for War. The Matron, when appointed, will engage her nurses and other assistants, and will be held respon¬ sible for their conduct. Matrons, nurses, &c., will receive from the Purveyor such pay and allowances as may be sanctioned by the War Office. Whenever it is practicable to do so, a preference should be given in these appointments to deserving widows of Non-commissioned Officers, if found to be as competent as other applicants. Local Committees might select widows or unmarried daughters of Non-commissioned Officers to be sent to King’s College Hospital for training as midwives. The offices of matron and midwife should, when practicable, be held by the same woman. 8. Matrons and nurses in Female Hospitals will obey any regulations respecting discipline, and the proper discharge of their duties, which may from time to time be issued for their guidance. 9. The Matron or Nurse shall receive and obey the Medical Officer’s orders in all matters relating to the care and nursing of the sick ; general management and cleanliness of wards ; administration of diets and medicines, of enemas, &c. ; cleanliness of the sick ; the warming and ventilation of the wards ; and shall render to him whatever aid he may require in the wards. 10. In the event of a nurse disobeying the direc¬ tions of the Medical Officer, or being guilty of any improper conduct, the Medical Officer will bring the subject to the notice of the Matron, who will see that the cause of complaint is immediately removed. 11. If the Medical Officer is not satisfied with the result of his representation to the Matron, or if he is not satisfied with the manner in which the Matron conducts herself or performs her duties, he will notify the specific case directly to the Committee of Ladies, who will immediately take such steps as they may consider necessary, reporting the same to the War Office through the Officer Commanding. 12. Reprimands, suspensions, or dismissal of nurses for neglect of dpty. or for misconduct will proceed solely from the Matron ; and similar acts of discipline exercised on the Matron will proceed direct from the Ladies’ Committee. 13. When subscriptions have been raised for sup¬ plying articles for clothing, &c., to women and chil¬ dren while in the. Hospital, the Sub- Committee of Ladies already mentioned will superintend the issue of such clothing, and the Matron, or Nurse, as the case may be, will account to the Sub-Committee for all articles issued. 14. The Ladies of the Sub-Committee will be entitled to visit the Hospital daily at such times as the Medical Officer may appoint, and will also have the power at any other time of visiting patients who may specially send for any of them. 15. During such visits the ladies will not interfere with the treatment or nursing of the sick ; but if any matter comes to their knowledge which in their estimation concerns the welfare of the patients, they will, if it refers to nursiug duties, bring it to the notice of the Matron, or if it concerns the Matron herself, they will bring it before the Ladies’ Committee. 16. Chaplains will have the power of visiting the sick at such times as may be ai’ranged in concurrence with the Medical Officer in charge, and at other times when they are specially sent for by patients. 17. Friends of patients in Hospital will be admitted at times appointed by the Medical Officer. LONDON: Printed by George E. Eyre and William Spottiswoode, Printers to the Queen’s most Excellent Majesty. Eor Her Majesty’s Stationery Office,