ITERS TO NURSES FROM FLORENCE NIGHTINGALE, JuneJ897,and February, 1868. Reprinted for the Nurses of the Liverpool Queen Victoria District Nursing Association, by April, 1913. ^ It i>L 1 To the Nurses and Probationers trained under the " nightingale fund." London, Jane, 1897. Dear Nurses and Probationers, My thanks to you all. God bless you all every one. And what does His blessing mean to us nurses ? Does it not mean that, as nursing has to do with life and death (the greatest gifts of God), with the body which is the " temple " of the Holy Spirit, all our " works " in it must " begin, continue and end " in Him to His " honour above all things " ? If God has given us this calling (nursing to His honour), He has put His honour into our hands. If we let it go down, we are dishonouring Him ; we are making it a mere matter of silver and pence. II. (i) A good nurse must be a good woman. A good woman is one who gives the best of a woman — intellectual, moral, practical — to her patients, under the orders of a doctor. Would you offer less than your best to God ? (2) What should be the characteristics of the good woman ? Discipline. The highest discipline is when every woman on the hospital staff works as one, " as members of one body." Loyalty to one's corps and one's chiefs. Peace and goodwill to all. Love and humility, for without humility there can be no real love or good will, but much ill will. Kindness. I must add good habits, and I may almost add joyfulness in one's work. Are not these some of the characteristics of the good woman ? Nursing should not be a sacrifice, but one of the highest delights of life. (3) Nurse Harvey (the probationer we have lost) was one of these. Her life was in her work. She took as a " handsome present " every new thing that was taught her, and all her cry during her too short illness was, " Won't Matron let me go back to the ward to-morrow ? " Some may think that her last words ought to have been about looking forward to the next world. Surely God would accept her looking forward to His work in this world as the best preparation for death. Is not life the only preparation for death ? But I have another death to tell you of — that of one whom perhaps few of you will remember as I do. She was Night Superintendent at St. Thomas'. She had all the elements of a great teacher, the experience that a night superintendent must have, all the elements of a great leader, like a captain going before his men in war — the war against disease — all the elements of a great mother. She trained the night nurses every night. If anyone did not know what to do, as not seldom was the case, she could tell them and show them with her own hands and out of her own experience. They looked to her. She never failed them. She kept up their tone, kept up their spirits, she mothered them. She left us to take military service, and for years she was the head of the typhoid wards in one station. The position of a head nurse over orderlies is difficult, because it is not defined. But she was better than a " Regulation," She taught them nursing, cleanliness, hygiene. She taught many of them to live better lives. If they complained that promotion was given not to nursing, but to clerks' work, she would say, " Then practise your figures and your writing, youVe plenty of time, and you will be promoted too." I saw her here only two months before her death on her way out to take her turn on foreign service, and thought she would survive me thirty years. She died almost suddenly, and when the sad news came her orderlies were grief-stricken and wept like little children. I have yet another to tell you of, who has just now died after a painful illness. She was our first Sister Victoria (Children's Ward) — the one who, if she did but hold up her finger, the little patients stopped crying. That is, perhaps, an unusual power, born of unusual love. But cannot we try to imitate her ? If you knew what a difference it makes when a kindly nurse has to go down the Ward to the door, if, as she passes, she nods to one child, smiles to another, says a cheerful word to a third (it was a nurse told me this, who did it), you would not pass the children as if they were so many mummies. Children often cry because they feel so desolate. You may say ; then we want as many nurses as we have children. Yes, but if there are some dear five or. six year old patients, it leavens the whole mass. Such from the cradle to the grave is our influence over one another. Some one said that the strongest influence we know is that exercised by a child of five taking care of a little one of three. Sister Victoria, as she will ever be to me, sent me a message, as she lay dying, that she had ever been faithful to the nursing work, had always done what she could. And it was true. Never was there a sick person, rich or poor, within her reach that she did not do for, as no one else could. She was not the most unselfish person you ever knew ; she had no self. III. The extension of District Nursing has been so great, that of Private Nursing has been so enormous, that some words must be given to each, besides to our particular subject— Hospital and Workhouse Infirmary Nursing. A thing was said to me the other day, which, though it related only or chiefly to Private Nursing, should give us cause for practical thought — even painful thought. It was this : " Nursing has been invented, now it has to be reformed/' 6 It is true that we are the fashion, but what does fashion mean ? It means decay. IV. Let me note here in passing. Every year we know more of the great secrets of Nursing. One is the Asceptic. [Now I am doing exactly what we ought to be told not to do — i.e., never use a Latin (or a Latin-Greek) word where you can use an English word.] But we have been eminently taught this Asceptic by our Doctors and Surgeons in their Operating Theatres. We have to carry it out in our Nursing. Septic means blood-poisoning ; Antiseptic means using certain substances supposed to counter- act blood-poisoning. Asceptic means doing away with everything that can possibly produce blood- poisoning. Asceptic means absolute cleanliness. A great Doctor, a friend of mine, says, " Call it germs, bacillus or dirt, the treatment is the same — that is, cleanliness/ ' Never let Doctors have to say of us what they have said of some Nurses : " She knows as many words as I do : but she does not know how to make a patient comfortable." V. Hospital Nursing. (i) And first let me whisper a thing which probably you are all of you aware of. Primary Education has made our patients, especially our new patients, much sharper than they were, in observing us and of course in criticising us. ' Is the Sister worthy of her calling ? " " Will the Probationer get her uniform ? " And (but I hope this is never heard now) " Probationer does not come when I call her to ask for a drink ' (or something). (2) Nursing is in general made up of little things; little things they are called, but they culminate in matters of life or death. Here is an old Hymn : Teach me, my God and King, In all things Thee to see ; And what I do in any thing, To do it as to Thee. The housemaid (but, say, the nurse — especially the nurse) with this clause Makes drudgery divine Who sweeps a room, as for this cause Makes that and the action fine. 8 (3) Children require the most observing and best nursing because they cannot tell you what they feel, and, what is more, a fretful complaining child is by no means always the most suffering. Still, you must not neglect fretfulness. Love for children is a necessity in a children's ward. There are two aspects in which a children's ward presents itself. One is that there is much dirty work which there is not in adult wards — it is by no means an angel's ward — and much noise, which, however, a skilful, loving nurse can much diminish. If she can stop the elder children from crying, the babies will often stop. But there are some causes for crying which ought to be prevented, and can be prevented, and are not always. They must be either " those dear little souls " or " those tiresome dirty things." One likes to see in a Victoria Probationer's diary " My three babies " — " changed my seven children." And often one does hear this. The other aspect is the ready response of children to real feeling. A little boy was heard to say to the children nearest to him : " Bobby " — that was the child in the bed opposite to him — ' is dead ; sister has carried him into the corridor." She had washed and dressed the little corpse first as if it had been alive — " And do you know, God was waiting in the corridor to carry him to Heaven." How different this, from what he might have heard elsewhere — that Bobby was gone into the black pit. The little witness to Bobby's resurrection died soon after him. We had a little boy in hospital in an adult ward of men about six years old. He was an incurable spine case. When he came in, he literally could not speak without an oath. The sister did not scold him, but by degrees, after placing his bed between those of two young men she could depend upon, she taught him his little prayers and his little hymns. And he would call out " Sister, I have not said my prayers/' and put his arms round her neck and pray. And with the tail of her eye she would see one of the young men crying and putting his head under the bed-clothes. Perhaps he was thinking of the time when he, too, said his prayers at his mother's knee. This child became the little missionary — the salt of the ward. No one said a word or sang a song he ought not to hear. The dressers were so fond of him they carried him about. He was never goody, never preached like the children in little good books, he was always a little -elf, but a conscience developed itself, and when, after IO two years, the Hospital could keep him no longer, and he was put with some " Sisters/' he would not ask for the sweets given at Christmas. That was a glorious self-sacrifice. After two more years there he died. A little boy of three, who was crying with pain after an operation, stopped himself from crying with, ' God has pain, but He does not cry." (The child's own words.) (4) There are some advantages, I think, in putting children above infancy, and old enough ta feed themselves, in an adult ward. There they cheer the other patients, who are delighted to take some care of them, and are happier themselves, and it is more like home. In well-nursed workhouse infirmaries, the children sometimes say of the Sisters' words, " it is the first ' good words ' we ever heard." And one little girl, whom her bad parents were going to take out, was heard praying behind her cot that she might not forget the good " words " she had heard. Speaking generally, children, and even adults, in hospitals and in workhouse infirmaries remind one of the parable about bringing in from the highways and hedges those who were to share the Lord's II hospitality, while we, who have been invited from our childhood, we do not come. VI. Workhouse (Union) Infirmaries. It is extremely likely that as the population of London increases (it has almost doubled in my time) and the populations of other great towns increase and almost overflow the hospitals, hospital cases will more and more be sent to these new infirmaries. Happily, we may now look up to many of them, and to the training they give, and the revolution they, in their improved nursing, have effected. How we ought to thank the pioneers, those who have begun, and those who have thus far carried out this great reform in the nursing. All hail to them ! I do not mean that there is not still a great deal more to be done, both in town and country, especially in the country, where the solitary trained nurse has not even the rank of a school-mistress. I will not go back to the time when, in the old workhouses, the favourite Sabbath amusement of the sick male wards was to shy their tin plates and cups at each other across the ward, and then send for the police and give each other into custody. 12 In many an infirmary the policeman might have almost been called the night nurse. All that disappeared at once with the educated and trained nurse. She became the powerful policeman. She is the salt of the wards. But let me allude to certain advantages which the modern workhouse infirmary has over the hospitals. There is such a " drive " in the hospitals now. Operation cases are got out as quickly as possible to make room for other operation cases. There is more time to do good to an infirmary case. It is true there are many infirm cases for whom at first sight it would seem that little can be done, except to treat them as idiot children. But this is a mistake. A clever kind-hearted nurse addresses an old woman, who perhaps has not spoken for months, and been a most troublesome patient (she has looked in the register for the old woman's occupation). " Oh, you were an orange-woman weren't you ? — How much did you sell an orange for ? A penny. Yes ; and I daresay you gave a penniless boy an orange. Bad for trade, but very good for the penniless boy." The old woman looks up delighted. The nurse has got a hold upon her. " Oh, you know 13 all about me," says the old woman, and one murmured, " Perhaps the Queen knows about me." So much for intelligent loving-kindness. It is said that the training in a large well-nursed workhouse infirmary is as good for a district nurse as in a hospital, because the cases are more like what she will have to see. A poor woman, left a widow at twenty-three, with five of her husband's children by a former wife to bring up, opened a little shop, worked like a slave till she was forty, got out all the children as apprentices or in little places, then at forty she collapsed in consumption. She was put into a workhouse infirmary, which she had much dreaded. She lived a happy four months there, and died there. She said, constantly, " I always prayed that I might have some time for thought before I died. And now I have had it in this beautiful place. Why, it is like heaven." VII. District Nursing. This is (or may be) the " Star of Bethlehem," the crown of good nursing, the modern civilizer of the poor, or it may be a very poor thing indeed. H Which it will be depends almost entirely on the character of the woman, for the excellence of the nursing may be the same in two opposite characters. It is multifarious in its powers and opportunities, for it is not only in the nursing of the patient, but in the nursing of the room, the teaching of the family or neighbour hpwT to help nurse, the teaching of how to keep in health as well as how to carry out the doctor's orders for the cure of disease, and the influence gained is not by preaching, but by what we are. Yes, even to influence over drunkenness. A drunken man or woman will not let himself or herself be seen twice in that state by the nurse, although she has not said a word. One nurse (the nursing is the same, say) will come in with a cheerful face and sympathetic voice — not put on — the real outcome of her character ; the whole family welcomes her as a friend ; the patient, who has been longing for her to come, cheers up. She has been a ray of sunshine in the lives of all. Another nurse (the nursing is the same) brings no cheerfulness or hope with her ; she performs her duty like a machine, and goes out again as she came in, like a machine, not particularly acceptable ; for, 15 although she may have conscientiously carried out the doctor's orders, she has left no sunshine behind her. The most experienced of district nurses said : " All depends on the first hour ; if the district nurse says, ' I hope to find all cleared up and cleaned up under the bed before I come again/ they want her never to come again/' It is quite easy for nurse the first to manage it pleasantly, doing it herself once, after she has made friends. Moreover, nurse the second has not called out the kindness of the poor as the first nurse has. The kindness of the poor to one another is something beautiful. A district nurse, in London, was called in to a child two months old, apparently dying of bron- chitis, in one of those tenements so common in London, many stories high, with one room on each side the stair, and a family in each room. In the room, with the two months' old child — of course illegitimate — were the mother, aunt, and grandmother, all drunk. The child was in an indescribable state of filth and vermin. vSeeing how the land lay, the nmse ran upstairs, and in the first room, at which she knocked, the woman gave her a clean little nightgown ; in the i6 second another woman gave her a clean bit of blanket to wrap the child in ; from the third a woman came with a handful of chips and a handful of coal to light the fire in the child's room, but a fourth came with the handsomest present of all, a kettle full cf hot water to wash the baby in ; a fifth ran out to buy a ha'porth of milk for it, and would not have the ha'penny back. When the poor see a nurse who can be trusted, who knows her business, and to whom drink is impossible, there is nothing that they will not do for each other through her. But beware of the district nurse becoming an almsgiver. VIII. Private Nurses. And to these, God's honour is as much, perhaps more, entrusted than to any other branch of Nurses, to be maintained, perhaps, with more difficulty. For, except those Private Nurses who are attached to the Hospitals where they were trained, or to adequately supervised homes, they have no home, no supervision, no anything to keep up the tone of their high calling. 17 But they have God. If they knew how any touch of vulgarity, foolish jesting, loud laughter, gossip about their patients, weakens their own character, destroys the influence not only of themselves but of the body to which they are supposed to belong, whether they do or not, they would pause and ask themselves, " Am I supporting God's honour ? Am I even supporting the Nurse's honour ? " Then the Private Patient is so much in the power of the Nurse. Is her kindness, consideration, gentleness, courtesy, refinement, what the Patient has a right to expect ? Or is she caring for being waited on more than for waiting on her Patient ? The Private Nurse, like every other, must have proper sleep, time for proper meals, and, if possible, some fresh air every day. But it is for her to take care to provide fresh air for her patient's room, and that both by day and night. Private Nurses are sometimes spoilt, sometimes put upon. In this respect the Private Nurse is worse off than the Hospital or the District Nurse. Let her not allow spoiling to spoil her, and let her learn from being put upon not to put upon others. i8 Private Nurses must even more than all others work under Doctors ; otherwise they are quacks ; and what are we to say to a nurse who deliberately determines, " Doctor has ordered so and so, but I shan't give it " ? If it is something which she knows or fancies she knows by experience disagrees with the patient, let her respectfully explain to the Doctor. There are very few Doctors who will not listen to a nurse who talks gently and cautiously, like a woman who knows what she is about. A Hospital Doctor constantly desires the Sister to report to him upon this or that. That is because he knows she knows what she is about. IX. (i) Maternity Nursing is one of the great needs, but it is extremely difficult to organise satisfactorily. It must include teaching the mothers the feeding, washing, clothing of infants and children. Maternity leaflets, though excellent, are of little use. Teaching by practice is of great use. As to feeding, the extraordinary error is common that milk is not a food, but only a drink, and the 19 equally extraordinary one that the toothless child may have meat and solid food. " It has every- thing that we have/' is the constant answer you receive. We had a beautiful little boy of seven months old (would that it were the only case), in hospital. It was very ill, but entirely recovered under treat- ment and a milk diet, and was discharged. The mother fetched it away under special instructions from both Sister and " Resident " about its diet. In four days she came back, " Child's dead." You may imagine the horror felt. " Yes," she said, " and I gave him a good meal an hour before he died." " What ? " " Steak, bacon, beer." Who killed that child ? (2) A great change has taken place in my time about milk. People in the country who used to drink their milk at home now send it all to the great towns to sell. It is said that the effect is seen in our national constitutions, and that indigestion in children under two years is seldom or never cured. An inspector of infant schools is said to have reported that he had examined many hundreds of infant throats, and scarcely found one perfectly healthy. 20 (3) With regard to cleanliness, mother and child equally suffer from the want of strict cleanliness. The mother is left not properly washed for days after her delivery, and afterwards, and in their daily life, want of privacy prevents these most hard- worked mothers from washing. The infant's eyes suffer from not being cleaned at birth and afterwards. It is lamentable how many cases in blind asylums are blind from birth. (4) Many of the district nurses take a few maternity cases, visiting them twice a day, once before they go to their other cases, and then, if they return to their " home " for dinner, changing their clothes, etc., and taking the maternity case again before their other cases. But this requires the utmost caution. This, the neglect of mothers and infants after childbirth, is a national matter of importance. Conclusion. (1) There is no doubt that this is a critical time for nursing. Will you have women, or will you have words ? Which nurse best ? 21 There is a curious old legend that the nine- teenth century is to be the age for women, and has it not been so ? Shall the twentieth century be the age for words ? God forbid. i But words we must have, you will say. Undoubtedly, and the greatest disco vereis have generally given a large portion of their time for putting their discoveries into words which are intelligible to the common people like you and me. Mrs. Somerville was an astronomer famous for this, and I remember when I was quite a girl hearing my mother complimenting her on her " genius." ' Genius, my dear/' said Mrs. Somerville, " there is no such thing. There is industry and regularity. I write every morning of my life from 7 to n. I allow nothing to interrupt me. From 11, I see the scientific men who wish to see me." There appears to be some danger of our being suffocated with words, of our thinking that we can learn nursing in six ambulance classes. This is now so common a superstition — I can't call it anything else — that circulars announcing such classes reach me continually. Nursing takes a whole life to learn. We must make progress in it every year. It takes five years, not of wrords, but of practice, to make a ward sister. 22 There seems some danger that the twentieth century will be an age not of facts, but of enthus- iasms without facts. (2) Let us run in another current. The patient is to us a threefold interest ; the intellectual interest as a case, which requires the closest observation of facts, to be explained by the lecture and the clinical teaching — the moral interest, as a fellow-creature to whom we must do, while under our care, either moral good or moral harm — the technical interest, whereby we learn what to do for the patient, and how to do it, under the orders of the doctor. Let us try to fulfil our obligations to our patients in God's strength (not our own) in all these ways. (3) It has been recorded that the three principles which represent the deepest wants of human nature, both in the East and West, are the principles of discipline, of religion, of contentment, this last not meaning that we are to be stationary, but just the reverse. It means that our education is to fit us for our business in life — not to be merely ornamental or clerkly — that we are to make progress 23 with the calling we have chosen, and not with registers, uniforms, or the outward forms. (4) Nursing is not an adventure, as some have now supposed : " When fools rush in where angels fear to tread." It is a very serious, delightful thing, like life, requiring training, experience, devotion not by fits and starts, patience, a power of accumulating, instead of losing — all these things. (5) We are still only on the threshold of training. Till every mother knows how to feed, clothe, wash her children, especially under two years of age, so as to secure them the best chance of health ; till every sick poor person can have a share of a trained district nurse ; till every private nurse has some organisation, some principle of life, a higher idea of what a private nurse should be ; till there is no longer any danger of words taking place of women, we are not far beyond the threshold of training. I pray that we may know the times and the seasons, and be true to our calling. God help us all. F. N. 24 To the Nurses of the Brownlow Hill Workhouse Infirmary, on the Death of their Matron, Miss Agnes Jones. London, February 22nd, 1868. Dear Nurses and Fellow Workers, I wish I could tell you in few words how much I feel for you and with you. But my words must be few; and what are my words compared to hers, who is gone ? But who being dead, yet speaketh — and she does speak — she would say, Live to carry out the work which I did for God, for Christ's sick poor. Don't let them suffer because I am caHed to my Father. Indeed, dear fellow mourners, I scarcely ever knew any one who lived and died to do her " Father's business " as she did. Don't let this great sacrifice be in vain. Let us live to complete her work. But, you will say, we have lost our general. Then let us fight the good fight all the more as soldiers of Jesus Christ. You don't know how many battles, which seemed desperate while the General lived, have been fought and won by the soldiers who, when they saw their General fall, fought, determined to save their General's name and win the ground he died for. 25 And shall we fight less stoutly a Heavenly battle, a battle to cure the bodies and souls of God's poor — less well than men who have fought an earthly battle to kill and wound, for earthly glory or at least for earthly liberty ? I am sure she will never have to say this of you. But the battle is long. Yes, and so is the strength which God gives. Let us run with patience the appointed course, the race, the combat to the end. Don't let her say to us in another world, that we left her work unfinished. Scarcely any one has lost more in her than I have. It made me happy just to think of her work and yours. Who could have thought that I should have survived her ! I could almost envy you who have been always with her these latter years, and envy you too, because you have the more immediate opportunity to finish her work, which she has so nobly begun. You know almost better than any others what she wished, what she wanted to have done. You are those best fitted to carry it out. Do not let us be cowardly, now she is gone, who was so brave in God's service. That would be a poor love to show her. The greatest love we can show her is to do as she did and as she would have us do. This is the time, the best of all, to hear God's voice — this time of sorrow, of never to be forgotten misery, which seems so like a wreck of all we cared 26 for. But if we listen we shall hear Him say, as Christ did in the storm, " Lo, it is I, be not afraid ! " And we shall answer as Samuel did, " Speak, Lord, for thy servant heareth." Answer not only to-day and to-morrow, but every day for the rest of our lives — answer by working on patiently and bravely, at His work and at hers — for His sake and for her sake. Let us return thanks for having known such a good servant of God. Next Sunday I shall take the Sacrament and try to offer up my soul and my body — all that I am and all that I have, in full confidence that God will enable us all, you and me and all of us, to do it as she did following after the Saviour who did it for us all. God bless you all. Your affectionate friend and fellow mourner, FLORENCE NIGHTINGALE. Note. — The Nurses to whom this appeal was addressed were the first set of trained nurses to be introduced into any poor-law hospital. For some months after Miss Agnes Jones's death they carried on the work without any Superintendent, in spite of great difficulties, lee a Nightingale. PRINTERS, LIVERPOOL. )'