Buffalo Township (part 3 of 6)

Rebecca S. Strong

Ladies, I must thank you for the honor you have conferred upon me by asking me to read a paper on the " Preparatory Instruction of Nurses," and presume it is the technical course of study to be pursued before entering the wards as probationers for practical training in the art of nursing which you desire to hear about, and not the ordinary preliminary general education which is a sine qua non. I ask your indulgence should I digress somewhat from the particular point, as it is a wide subject, with many side issues. I will endeavor to place before you something of our work and aims on the other side of the Atlantic, and the various events in the " chain of evolution " which have led to the desire to rescue nursing from its chaotic condition, placing it on a sound basis of systematic tuition, leading on to a final examination, to be conducted by an outside body, under the control of the State.

by them of the studies, examinations, and work to be done, before a woman presents herself for examination for her diploma. We cannot be a separate independent body, we are the hand-maidens of the medical profession ; and if we educate ourselves beyond what is required of us, it is valuable time lost, and is apt to produce a spirit of discontent with the subordinate position which we must hold in regard to the doctor. On the other hand, we require to keep abreast of the times, and if we do not educate ourselves to meet their needs we cannot expect their interest in us. Diagnosing is not our province, our responsibility ends with a loyalty of spirit in carrying out the instructions given, obeying in spirit as well as in letter ; and it is only by being at one with the doctors, supplying their wants, that we can look for guidance and help from them in the forming of ourselves into a recognized body of people.

I cannot say that my ideas are representative of the thought of the country, they are merely the gathered experience of a thirty-five years' nursing career.

The medical profession is by no means unanimous, in our country, as to the necessity of a fixed curriculum for nurses, and what should constitute a " Trained Nurse " (I use the term for want of a better), but it must be borne in mind that it was only in the eighties of last century that that profession became a corporate body. We can scarcely expect in so short a time that the want should be universally felt of a body of women specially educated on fixed lines to give assistance to them in their work. Physicians and surgeons will always have their individuality to be considered with their methods of treatment ; but a nurse must have a certain amount of information before she is capable of adapting herself to their various requirements, otherwise it would entail a great deal of misunderstanding of instruction given. We would like to do away with what is so aptly called the " daring of inexperience." There are many medical men who are of opinion that the time is not far distant when the term " Qualified Nurse " will require to have a definite meaning and not be left to the arbitrary decision of the various hospitals to j^rant certificates, following upon their own private examinations, which may or may not be of practical value in regard to the fitness of the holder for carrying on the work of nursing.

The argument that there are many good nurses who have received little but empirical training will not hold good, any more than the same applied to the practice of medicine half a century ago. As it stands today with us any woman who holds a certificate to the efifect that she has spent three years in a general hospital containing not less than forty beds can register, provided there is nothing against the moral character.

It is not the size of the hospital I object to - given a good doctor and a capable nurse in charge, who would not grudge to devote their time to teaching, I believe the best results may be obtained. What I maintain is, that residence alone is an insufficient guarantee of ability, or fitness for the work, without some test of the knowledge gained during the period of residence in hospital. This, I think, is where registration with us fails to meet a much-felt want. The fact of there being an examination by an outside body would be a valuable stimulus to the nurse all through her term of residence, and would do something towards preventing merely mechanical work, adding zest, thus causing happiness, which we cannot do without.

We speak of the old and new order of things, if we compare the generations one with the other ; it seems like constant revolution, but in reality it is a succession of events leading to changed conditions. There is no break in the link ; it is progress, not revolution ; it is the same with the so-called " Profession of Nursing."

As the science of medicine has advanced, a more intelligent assistance has been called for by some, an instructed intelligence, which can grasp the meaning of technical instructions left for the guidance of the nurse. To prevent repetition of platitudes, you will find my ideas on this point in a printed form, which any of you may have upon application to me at the close of this meeting.

When I first entered St. Thomas' Hospital, London, nearly thirty-five years ago, a year's residence was considered sufficient length of time to prepare one for the taking of responsible positions, even to that of matronship. I am sorry to say this custom is not yet quite obsolete in some of our British hospitals.

The year mentioned was an immense improvement upon what had been, before the time of Miss Nightingale establishing her school at St. Thomas' in conjunction with Mrs. Wardroper (matron of that hospital), after Miss Nightingale's return from the Crimean War.

The value and far-reaching influence of the work done by that lady requires no comment from me, it will live for ever. For Mrs. Wardroper I would like to say one word. The single-handed combat which she undertook, with the general bad condition and ignorance which prevailed at that time in the nursing world, was being nobly fought, when Miss Nightingale, in search of a hospital wherein to establish a school for the training of nurses, came upon and recognized the good work being done by Mrs. Wardroper, and chose St. Thomas' Hospital as the center for her operations. This school being established class work was gradually introduced, in addition to the practical work, until it has grown into an elaborate system, and, as I have remarked elsewhere, had St. Thomas' remained the only training school for nurses we should have had uniformity, and possibly the authorities would have risen to the demands made upon them ; but, as there was perfect freedom in the matter, a legion of schools, so called, sprang up, each establishing according to their individual ideas a curriculum for the instruction of their nurses, producing a veritable chaos of training. We require to know the method of each school before we can estimate the value of the certificate given.

Looking back upon my own early experience, and the work undertaken by me, without knowledge of the construction of the human frame, its functions, and the hygienic laws pertaining to the m.aintenance of health, and my ignor- ance of the leading features of disease, and inability to distinguish between healthy and unhealthy excretions, with the inevitable blunders arising therefrom (in fact learning through blunders, which is not to be commended where risk to life is involved), I concluded that it was necessary to be acquainted with these matters before entering the wards, to be instructed in the practical art of nursing, as there is too much close study entailed in acquiring the elements of these things to admit of classes being carried on simultaneously with ward work.

Professor Macewen of Glasgow University was the first to suggest to me the possibility of an organized uniform method for the technical instruction of nurses, before entering hospital as probationers for practical work, with final examinations, after a fixed period of residence, by an outside independent body representing the State, whose diploma should be the sole guarantee of fitness for the office of " nurse."

It was on the New Year's morning of 1891 that Professor Macewen, in an address to our nurses, first made public mention of what he thought might be done in this respect, and added, " Will the Glasgow Royal Infirmary take the lead ?"

Scheme Of Education As Adopted January 1893

In consequence of his representations to his colleagues, a scheme was drawn up by our staff for a series of classes for pupils who desired to become probationers. This scheme was placed before our managers, and they very heartily consented to a trial. We made a start in January, 1893, and from that time we have gone on with our pioneer work, each year strengthening our confidence in the soundness of the step taken, though keenly alive to the necessity of fuller development. The intending pupil (unless holding a Leaving Certificate of the Scottish Education Department, or one in connection with the University) is required to attend a preliminary examination in Grammar, Composition, Spelling, and Arithmetic. Ordinary physique and good general health are indispensable. The first six weeks are spent in attending classes (especially arranged for nurses in connection with St. Mungo's College, Glasgow) for the acquiring of the elements of Anatomy, Physiology, and Hygiene, for which the pupil pays £2 2s., providing board and lodging at her own expense. It would take too long if I fully detailed to you these classes, but I will give you an extract from our syllabus.

" The Anatomy course consists of not less than twelve lectures, embracing the description of the bones, joints, and chief muscles of the body, the course of the main blood vessels and nerves, and the broad outlines of the anatomy of the brain and of the thoracic, abdominal, and pelvic viscera, illustrated by diagrams, casts, and recent dissections. These lectures are given by Professor Henry E. Clark of St. Mungo's College. Oral examinations on the subject matter are held throughout the course, closing with a written examination by an outsider. This method of examination, I may say, is carried out in the other subjects, i. e. Physiology and Hygiene."

Physiology also consists of twelve lectures given by Professor John Barlow of the same college, illustrated by diagrams, instruments, and by microscopic preparations - the subject matter comprising a description of the blood, muscles, food, digestion of food, circulation of blood, respiration ; the skin, kidneys, nervous system, general arrangements of parts of the brain in man, and the special senses.

Hygiene is taught by Professor Hugh Gait, also of the same college, consisting of twelve lectures profusely illustrated by models and diagrams, and including the general principles and fundamental laws of Hygiene. The dwelling in relation to health ; air, ventilation, water ; the various methods of heating and lighting are all very carefully considered. Hygiene for nurses in regard to personal clothing and food, and in regard to disease is entered into, and the general principles upon which buildings constructed for the treatment of disease should be erected.

Upon the pupil passing successfully the examinations connected with this first course, she goes on to a second course, for which the sum of £3 3s. is paid. This course comprises twenty classes or lectures by Dr. James A. Adams, surgeon to the Royal Infirmary, on the nursing of cases before and after operation, according to modern ideas of surgery, in relation to the germ theory, including the operating room and its equipments.

Fractures, dislocations, haemorrhage, dressing of wounds, instruments, the application of splints, bandaging, etc., are all fully dealt with, several classes being entirely given to practical work.

Lectures and demonstrations on medical cases are given by Dr. Lindsay Steven, physician to the Royal Infirmary, consisting of lectures and occasional demonstrations in the wards of the lecturer.

The chief diseases of the various organs are briefly described, attention being specially directed to the training of the nurses in (1) What and how to observe ; (2) What is required in regard to nursing; and (3) What to do in emergencies.

Instruction is also given in the observation of the pulse, the respiration and the temperature, and the excretions generally ; in the examination of the urine, the administration of medicines, and in the signs of poisoning by the more common poisons employed as drugs in the treatment of disease.

A series of classes, ten in number, are also held by myself, comprising practical instruction in the cleaning and use of ward appliances, preparation of surgical dressings and methods of keeping such, care of instruments, preparing and application of fomentations and poultices, application of ointments, blisters, leeches, etc. ; special attention being given to the care of beds and bedding. Syringes of all kinds are explained, and their uses, with different methods of cleaning.

ticulars of this work have been published, and I take it for granted they are already known to you. This scheme excludes all class work during the three years spent in the wards, the time given to the acquiring of practical skill in the art of nursing. On looking over our syllabus you will observe that the three months' preliminary instruction is given entirely at the pupil's own expense.

Up to that time we, in common with others, had gone on increasing our class work until it came to be a serious hindrance in the work of the wards, being detrimental to teachers, nurses, and patients. Examinations were a constant " Nemesis," giving no freedom to really enjoy work, and with insufificient leisure to study the subject matter given in lecture, much of the good of it was lost. We could not see our way to less than a ten hours' day of ward work, and classes in addition to this interfered with both sleep and recreation.

Advantages Of New Scheme

One great advantage of the scheme is that it rids us of the incubus of a number of unsuitable women entering the wards upon a month's trial. I do not know which to pity most, the nurse or the probationer, where the old custom still prevails, and believe some good pupils are lost through the difficulty of getting accustomed to the extremely new environment into which they are thrown, whereas, by being gradually led into it through a preparatory course, they might succeed ; it also ensures a uniformity of instruction, and we know exactly what to expect from each probationer.

I should like to see this modified, as I do not think nursing is sufificiently remunerative to compensate for any great outlay in the gaining of the knowledge necessary for the carrying on of the work, and I would advocate the taking of the first course, viz., Anatomy, Physiology, and Hygiene, at some established medical school, independent

I have attended the classes under the auspices of the Royal Infirmary, Glasgow, which are held in St. ]\Iungo's College of that city, regularly, and am of opinion that the ground covered by the teachers is sufficient to enable a woman to carry on her work at the bedside intelligently, and I have no desire to see these subjects extended. The fees for these classes could be minimized by large attendances, if all hospital authorities agreed in not taking pupils for clinical instruction uptil they held certificates from the different recognized schools for the teaching of these three subjects. Each large town possesses at least one such college, and hospitals situated in smaller towns, where they have not the same facilities, might combine to insist upon their pupils holding these certificates.

I have not mentioned Chemistry, as both Physiology and Hygiene touch upon this sufficiently for the purpose of nursing, but we want uniformity, and this can never be attained without a central controlling power to regulate these things for us. One distinct gain we should have in the above would be, freedom from a preliminary examination, as the woman who could pass the examinations connected with the first course would certainly possess sufficient general education for the second.

I think the Clinical classes should be undertaken by the hospital authorities, each for themselves, the nature of these also to be fixed, being confined entirely to the general, no specialism. About two months should be sufficient to cover the necessary ground, the pupils paying fees sufficient to cover the expenses of lectures, the hospital providing board and lodging free of expense to the pupil with suitable class rooms, and the matron or lady superintendent, as she may be termed, taking general supervision of these classes, and seeing that efficient tutorial assistance is given to the pupils, in addition to her own proper classes.

The nature of this teaching as adopted by us, and the subjects we think it necessary for the pupil to be instructed in, I have already mentioned. We also endeavor to impart some principles upon which self-education may be carried on during the three years' perfect freedom from class work.

I should like to see more time devoted to this second course of instruction than we are at present able to give to it, and that is why I advocate the lessening of the expense to the pupil, that she may not feel it a hardship in lengthening out the time. What we cover in one month I think requires two. One hour's class work. I think, requires the whole of the remainder of the working day for study, either mentally or manually.

The pupil, on entering upon the actual work of nursing under the tuition of the " nurse in charge," to make herself practically acquainted with the ward duties and the individual care of the sick, should apply herself diligently to the understanding and practical application of the theory gained in class.

Unconscious tuition is constantly going on ; the Clinical classes, held for the benefit of the medical students, are of great use to the probationer in keeping her memory fresh, and helping her to understand the why and wherefor of things. The three years mentioned is none too long for the acquiring of the necessary skill to carry on so serious a work as nursing. We must not lose sight of the manipulative part of the work, which largely predominates ; in this, as in all other handicrafts, nothing but actual handling can produce skill. We might hold class after class, but all we can do is to give rules for guidance; books also can do no more. It is for the nurse to make the knowledge her own by practical application. We cannot ensure uniformity of skill in the carrying out of nursing, any more than in any other calling. Individualism will reign here as elsewhere; general adaptation and quick intelligence is not given to all, but we require a certain amount of definite knowledge.

If our larger hospitals must become recog-nized " Training Schools " for the supply of smaller institutions (where they have not the facilities for teaching) and also for the supply of private nurses, I think we should endeavor to accomplish these objects with a minimum of disturbance in the ward work. The constant change of probationers from ward to ward, to give them an insight into the different methods of working, was well enough in theory, but unworkable in practice. We found they were not long enough in any one place to take a grip of things, or for those about them to take sufficient interest in teaching, feeling they would be so shortly removed. We prefer them to take eighteen months in one set of medical wards before going to the surgical to take the other eighteen months, but cannot always manage this ; sometimes they have to take the surgical first. At the end of the three years thus spent in general medical and surgical work, we should like them to be examined by outside examiners from some recognized body, as I have already said, whose " diploma " should be the only legal guarantee for fitness for the work. Should the nurse be fortunate enough to obtain this, we should still be glad to retain her services ; should she fail, I think she should have the opportunity of returning to her " Alma Mater " and be re-admitted to examination later on.

Remuneration

At the present there is a great demand in our country for nurses who have spent three years in hospital, and with the human love of change we require to do what we can to make hospital life agreeable and healthful, and to give fair remuneration, otherwise we should be depleted of our best nurses, and our hospitals would thus sufifer from the use of them as " Schools for Nurses."

I think payment should commence as soon as a probationer is taken into the service of the hospital. I repeat,, nursing is not a money-making calling. The day is past when it was thought to be noble self-sacrifice to take up nursing. It is now recognized as an " honorable calling for honorable women,'' and I think it ought to be so arranged that women of moderate means are enabled to enter with the object of making a living, which object does not necessarily entail a mercenary spirit. I think it is a stimulus to the overcoming of the initial difficulties connected with the work. We do not wish to attract the dilettante class - we rather wish to exclude them; and I would emphasize what has already been ably said by Professor Macewen as to the desirability of equality in the work - merit alone carrying the day, and not the paying of fees nor purchase of the higher positions. We want women of earnest purpose, with no heroics, but sufficient interest in the work to be happy in it and to carry them through emergencies that may arise with a spirit of pleasure without feeling ill used.

Free from the worry of classes, I think it a most pleasant work, always varying with the myriad individuals and their myriad interests. I speak from the experience of twelve years spent directly at the bedside.

Domestic Work

I am aware that some may raise objection to the purely technical character of our scheme of preparatory instruction for nurses, and think we altogether lose sight of the domestic. This we can never escape from ; it is this domestic nature of the work which makes it essentially a woman's work, and I would advise everyone who wishes to perfect herself in the art of nursing to perfect herself first in the art of housekeeping, including cooking. I think it waste of time to come to hospital to learn these things, and they cannot be done without; they meet a nurse at every turn.

The whole condition of a ward depends on the nurse in charge. (Cleanliness is a much more scientific matter than appears at first sight.) We do not ask our nurses to do the housemaid's work of the ward, but we do ask for a thorough knowledge of the best methods of cleaning, that she may be able to direct. We have no system for the traming of ward-maids - I wish we had - and therefore have to depend upon the nurse in charcje for the g-eneral brightness and comfort of all under her. It is similar to an ordinary home, and we all know how much depends upon the head. It is sometimes quite distressing to hear an otherwise capable woman expressing her ignorance of the most common household matters, giving as an excuse the depending upon servants.

Johns Hopkins Curriculum

In looking over the circular of information kindly sent to me by Miss Nutting of the Johns Hopkins Hospital School for Nurses, I did so bearing in mind the characteristics of the two nationalities and their differing needs. In comparing the two systems, please do not misunderstand me, and think that I suppose either of the systems, transplanted, would take kindly to the foreign soil. Each has sprung out of its own particular need. It is interesting to know what others are doing, and we may be helpful to each other in this way ; beyond this we cannot go.

We see that during the first six months of probation, before the pupil enters the wards, instruction is given in household economics, food, hygiene, sanitation, anatomy, physiology, and materia medica. I must interrupt to say one cannot but feel envious at the well-arranged school for preparatory work, and wish some generous donor would furnish us with the same facilities for teaching. Well, after this six months comes eighteen months spent in practical work in medical, surgical, gynecological, infectious and orthopedic wards, not less than eight hours daily with an hour or two given to class work. This holds good through the two and a half years of ward work. The last twelve months are given to obstetrics, pediatrics, nervous diseases, and surgical technique, as taught in the various operating rooms. We go to the other extreme, giving a ten hours' day to ward work, banishing all classes during the three years spent in the wards ; exclusion of class work while in the wards being our main object in adopting a plan for the preparatory technical instruction of nurses. In addi- tion to this, we confine ourselves strictly to the acquiring of skill in general medical and surgical nursing during the three years, believing this to be the best course for us. I do not think the average woman of our country could cover more ground thoroughly, and, as I have previously said, we have the disturbance of the ward work in regard to the interests of the patients to consider.

Specialism Re Post-Graduate Work

I also think all special subjects should be taken up after a nurse holds her diploma for general nursing. I should like to see the day when it would be illegal with us for any woman to follow specialism, especially midwifery, without her diploma in general nursing - that is when we arrive at the " halcyon " days of knowing what that term indicates. So many complications arise in all forms of illness, that if a woman takes up any special branch of nursing, without a general training, she is likely to find herself in many difficulties.

General

Any measure of success attending our enterprise is entirely due to the enthusiasm with which all concerned threw themselves into the work. The medical men who kindly undertook the various classes have been untiring in their efforts to make the two courses as useful as possible, and the coming in daily contact with the pupil through the whole term of residence, viz., the three years, is most helpful in keeping up her interest and seeing that she makes the best possible use of her time.

Our nurses in charge have almost all passed through the same course of instruction, and are most helpful to me in seeing that the practical nursing is well taught ; not only in this but in my own classes held during the second course I should be at a sad loss if it were not for the ready help I receive from them. Last winter our charge nurses in the medical wards kindly made arrangements for the practical instruction of the pupils in the taking of temperatures, pulses, study of excretions, and testing. The resident doctors also kindly assisted in giving lessons on the position of the organs, etc. T must thank one and all ; without co-operation the matron is helpless. The intimacy arising from the contact with so many of her future fellow-workers is most beneficial to the pupil, taking away much of the strangeness of the new surroundings and cultivating a spirit of good will. Thanking you for your patience in listening to me, and your interest in our doings, I now conclude with the hope that we may all go on with earnest purpose, ever keeping before us the highest ideals.

Addenda

It may be of interest to you to hear something of the history of the nursing in the Royal Infirmary during the last quarter of a century. At the beginning of that period a nurse had to commence as a semi-wardmaid, under the name of assistant nurse, and work her way without any direct instruction. She was called at 3 a. m., commencing work at four, which included the ordinary cleaning, such as grates, scullery and bathroom, sweeping of ward, dusting, etc. Carrying of food, for the ward supply, and the washing up of the dishes had also to be done by her, and much carrying which is now done by men. Her duties ended at 8 :30 p. m., without any definite time ofif duty. This so-called " assistant " obtained in the " surgical houses " only. In the medical the day and the night nurses did all between them, nursing and cleaning, with the exception of the ward being scrubbed out once a week by a little army of women, six in number, who went the round of all the wards in turn.

It was surprising to find the good nurses that were sometimes the outcome of this very empirical manner of obtaining knowledge, but these were certainly the excep- tions. We had better be silent about the majority, sit kindly in judgment, as the circumstances and conditions were to blame, not the women.

The most of these nurses slept in small rooms adjoining the wards, and took all their meals (excepting dinner) in the ward kitchens. Nurses and servants shared the same dining room, and had to carry a knife, fork, and glass with them. The nursing staff at this time numbered 76.

The managers were desirous of remedying this state of matters, and after much consideration a plan was devised for the carrying out of a building into the quadrangle to provide dining accommodation for the resident doctors, and utilizing their old rooms for the nurses, providing suitable dining accommodation with proper table equipments.

An attempt was also made to separate the house work from the nursing, and was partially brought about by the appointing of a woman to every two wards to do the roughest part of the work. A time table was introduced, which allowed each nurse two hours off duty daily and shortened the hours on duty. A uniform dress was also supplied to the nurses at the expense of the Infirmary. Lectures were instituted to enable them to have a better understanding of their duties, but these were a questionable boon, as they had to be a,ttended at the cost of sleep or recreation.

The remuneration was increased, commencing with £12 the first year, £20 the second, increasing £2 annually until it reached £30, and three nurses were placed in each ward instead of only in some.

In 1882, when the present dispensary buildings were reaching completion, a representation was made to the managers of the insufhciency of the old dispensary buildings to provide the necessary accommodation for the nurses, and suggestions were made to them for the building of a " Nurses' Home " apart from the main buildings, where the nurses might have suitable sleeping and recreation rooms. The managers most readily accepted these suggestions, and the late Mr. William M'Ewen, at that time chairman of the " house committee," raised money for the express purpose. In 1887 a Home for 75 nurses was completed and. opened ; this, with the two corridors occupying the site of the old dispensary, gave accommodation for 105 nurses, and at that time it was arranged for them to take all meals in the dining room, with the exception of afternoon tea. In 1891 the bedside work had increased to such an extent that the three nurses were unable to accomplish the work required of them without undue strain.

The managers were again approached, and they granted permission to place a wardmaid in each ward to relieve the nurses of the household work. They also granted the erection of an additional flat to the Home, increasing the accommodation for nurses to 129. This enabled four nurses to be placed in each ward, but left a very small reserve for emergencies (two only), the probationers in the wards where the work was lightest being called upon to give assistance in wards where the work was heavier, so that the four nurses came to be more nominal than real.

In 1892 a scheme was placed before the managers whereby the nurses might be relieved from all class work during their three years spent in the wards acquiring the practical art of nursing, as this in itself was a greater hindrance to the practical work of the wards, and occupied much of the nurses' sleeping or recreation time. This also was acceded to, and has proved to be a right step by its very great success ; it also ensures uniformity of teaching in regard to the technical requirements of the work. It may yet be enlarged upon, and further developed with advantage to all. In the early part of 1900 further demands arose, in the form of a nurse (for each surgeon) to prepare dressings only, and this being in accordance with modern surgery, in which the whole aim is to obtain the perfect purity of the dressings which are immediately applied to wounds, this also was granted ; and a few more beds for nurses were obtained by the giving up of a waiting room, and also our sick room for this purpose. (Salaries were again increased at this time, the maximum reaching £35 at the end of five years' service.) The supplying of these nurses hampered us still more in the meeting of emergencies, and permission was given to get lodgings for six additional nurses, which is anything but comfortable for them. The resources of the old Royal in regard to administration are now taxed to the uttermost ; day by day the strain is felt. If some benevolent citizen of Glasgow would interest him or herself in the' nursing arrangements, and double the accommodation provided in the existing Home, they would be providing for the future well-being of the patients.

About forty nurses* bedrooms will be swept away in the demolishing of the buildings facing Castle Street, and accommodation is also badly needed for the pupils attending the Clinical classes in connection with our preparatory course of instruction. At present they have to provide board and lodging at their own expense, which is rather too much to expect of them, and is also much less satisfactory to us than having them within the building.

It is imperative that the nursing should be made attractive and accomplished with as little physical strain as possible, if the best work is to be got. The arrangements should be such as to cause our nurses to feel reluctance to leave their Alma Mater at the end of their three years' compulsory residence, and a voluntary service of an extra year or two should be given by them to enable us to build up an efficient permanent stafT, so that both objects may be attained, viz., a " Training School for Nurses " and an efficiently nursed hospital. The public themselves will ultimately profit by the improved nursing in our hospitals by being able to obtain for themselves a more carefully instructed nurse, l)Ut this cannot be arrived at without expense; and a more generous support is needed to enable us to carry out fully what we would like to do for the good of the patients, which should be the primary motive of all our movements in hospital.

No good nurse of the past will resent the forward movement ; it is they who are most keenly alive to the need of progress. They are thankful to those who have gone before, and left their knowledge and experience for our benefit. The aim of the present should be to leave a like goodly heritage. If we are not progressing, then we are retrograding. Who will come and help us to make our old Royal a household word, and a crown of glory to our city ?

Miss Dock : I have lately seen the working of the Johns Hopkins preliminary course and cannot commend it too highly. The whole nurses home is turned into a field for practical work. The pupils in turn learn every part of household work and management. They buy supplies, keep accounts, and learn to order and prepare food both in large and small quantities. Their bedrooms are exquisitely kept ; West Point cannot compare with them. For six months the pupils do not go into the wards. During this time they learn the management of a bed patient in class by demonstration, become familiar with all supplies and appliances ; learn how to make the different surgical supplies, and have instruction in hygiene, anatomy and physiology, materia medica, and the theory of practical nursing, with demonstration. When they go into the wards they know what they are doing, and are not raw probationers.

The preliminary education of nurses is in my opinion absolutely necessary and it is a question in which I have taken a keen interest for some years past. Mrs. Strong, the able matron of the Glasgow Royal Infirmary, and whose absence we all sincerely deplore today, was the first to propose and organize a course of preliminary training for nurses in Great Britain in the year 1893. The pupils are externes and pay for the cost of the course. Some years later a system of preliminary education for probationers was started in connection with the London Hospital Training School. A house was fitted for the reception of twentyeight pupils a short distance from the hospital, and a course of seven weeks' instruction is given in elementary hygiene, physiology and anatomy, together with practical instruction in sick room cookery, bandaging, splint padding, bedmaking, how to take temperatures, the names and the care of instruments and utensils, and various other useful details.

This school and course is expensive as it costs the hospital upwards of il,000 annually. In 1899 I outlined a somewhat more extensive course of preliminary training for nurses in a paper read before the National Union of Women Workers of England. It is much on the lines now being tried at the Johns Hopkins Hospital. A six months' course is, in my opinion, all too short a time in which to teach thoroughly all that a woman should know before being admitted to work in the wards. A more efficient system might be defined if the teaching extended over a year. The cost to the hospital would however be too great. A sounder economic policy would be for the pupil to pay for all preliminary teaching, and to meet her needs the organization of schools for preliminary training might be founded in populous centers, at which a thoroughly efificient curriculum could be carried out. This is a question of the utmost importance to the nursing profession and will no doubt at an early date receive the consideration it deserves from the superintendents of training schools on both sides of the Atlantic.

Mrs. Robb : It may be of interest to delegates who do not know that a set of papers on preliminary courses by Mrs. Strong, Miss Liickes and Miss Nutting appear in the American Journal of Nursing, in the first year's numbers.

I think one of the general reasons for establishing this course is that we have found few probationers who understand practical housekeeping as they should understand it. The special course in invalid diet alone is not sufficient, because the women are so vague or unpractical in housekeeping affairs that they do not get as much benefit from the diet school as they otherwise would. With few exceptions, our pupils are also unpractical in the general manag-ement of household details in the wards, and after graduating them we still feel that they are deficient in domestic economy. The respect in which private nurses are most severely criticized is that they are deficient in household economics. If pupils understood domestic science before entering training school, such a course would not be so badly needed.

Miss Macleod : A course of preliminary training in domestic science much on the same line as that referred to as in practice at the Johns Hopkins Hospital has for some years been carried out at the Waltham Training School for Nurses in Massachusetts. The course includes the training of pupils in housework, cooking and the preparation of supplies, and has proved of the utmost value in the education of practical nurses.

Lavinia L. Dock Introductory

The need of extending the two-years course of training for nurses in American hospitals to three years, and the benefits and improved circumstances to be gained both by the hospital and the nurse through this extension, were first discussed by the American Society of Superintendents of Training Schools for Nurses, in 1895, at which time a paper was read by Mrs. Hunter Robb, entitled "The Three Years' Course of Training in connection with the Eight Hour System.''*

*This, however, was not the first time for the public presentation of the subject by Mrs. Robb, as she had, in 189.3, advocated the adoption of three years with eight hour duty, in a paper read before the International Congress of Charities and Correction, and following this paper, two hospitals - the University of Pennsylvania in Philadelphia, and the Johns Hopkins in Baltimore - had inaugurated the three years' course in their schools.

This paper was in place of a report from a committee, which had been appointed the year before, to consider the establishment of the three years in training schools. The paper was accepted almost unanimously, and five years later, at the annual meeting of 1900, fifty-five schools in a membership of 124 reported a three years' course and five others a course lengthened over two years. Within the past year, and up to the date of this paper, a number of others in the society, now reaching over 70 in all, have adopted the three years' course. [The last report of the Commissioner of Education for the U. S., in a list of 433 hospitals gives 137 having a three years' course. This report, however, is dated 1900, and since then we know the number has increased greatly.]

The reports made to the society of Superintendents in 1900, with the individual information gained both officially and unofficially from hospitals outside of the membership of tie society, and from those within it which have recently adopted the new plan, have furnished the sources of information for the following paper.

Both from the standpoint of the hospital and of the nurses' training and education, the success of the lengthened course is unqualified. The hospital service is benefited by the longer stay of the pupil nurse, and by her deepened experience and better trained judgment. The medical staff feels the advantage in the less frequent changes and less noticeable breaks in continuity, w^hich, as we all know, they disliked in the short period of two years ward work for th'e nurses.

The steadiness and balance of the training school are markedly stronger, and the nurses realize the improvement in the diminished pressure of study and the greater opportunities for observation and assimilation of knowledge. So far, inquiries have not discovered a hospital superintendent, training school head, or pupil nurse, who would prefer to return to the old method.

How The Course Of Study Is Graded

It is only natural that in so short a period considerable crudity and want of finish should be found to exist in the curricula of the various schools. Time and the experience derived from experiment are needed to shape a curriculum completely, so as to include the necessary fundamentals, to cover all the special ground made necessary by the special conditions of the work of the hospital, and to include symmetrically the various elective courses and the higher branches possible in a fully developed scheme of three years training with adequate study time.

But on the whole, so far, it is evident that advance is being made in two lines at least : First, much more attention is being paid to the housekeeping and dietetic basis of nursing and of ward work. The new gospel of the elevation of every kind of domestic and manual work to a science is making its influence felt in our training schools, and is evidenced by the greater attention paid to the cooking lessons, by the more practical and demonstrative teaching of hyg-iene and sanitation, and by the growing demand for preliminary practical training. Second, the beginnings are noticeable all over the country, of the introduction of the elements of sociological study into the latter part of the course, and of a desire to have the nurse see herself and her work in relation to humanitarian and reform movements; to open her mind to the duty of the preservation of the public health, the value of preventive movements, and the relation of health and disease to morals and immorality.

These two tendencies seem the most encouraeine features of our lengthened courses. Theoretical and practical nursing had already been well developed, and need only to be further improved by a diminution of study cramming and bv shorter hours.

The Weaknesses Of The Three Years' Course

These may be found mainly at the beginning and end of the course in the absence of definite entrance qualifications, the lack of preparatory teaching before entering the wards, and indefiniteness in the higher professional branches of supervisory and executive work, such as will fit nurses to take positions of responsibility. Both weaknesses are well recognized, but the difficulties in the way of amending them are great. The inadequacy of an educational preparatory test, based upon book study alone, has long been tacitly acknowledged. The college graduate who has never worked with her hands, or learned to put things in their places, or felt the pressure of responsibility, has no advantage, through her excellent education alone, over the intelligent hometaught girl, who has always assisted her mother in the cares of a family, when the two enter a training school for nurses. The higher education is desirable and excellent, but for nursing a special preparatory training in practical things is urgently felt by superintendents to be necessary, if the three years' course is to be relieved of the burden of having to teach adult women all sorts of homely accomplishments which they should possess before they enter a hospital to

At present we have one school, * the Johns Hopkins, which has worked out a thorough preparatory course. It consists of six months spent in household work of every kind, purchasing and inspecting food supplies, preparing and serving every kind of food, both in large and in small quantities, and in keeping the financial accounts of the same. During the same period these pupils are taught anatomy, physiology, materia medica, the preparation of surgical supplies, and the fundamentals of practical nursing, in class, by demonstration with a subject. During this period the nurses do not go into the wards. The entire home of the training school is made a field for this practical work, and trained teachers are in charge of the different departments of work. This course, the fruit of Miss Nutting's experience and reflection, is, to my mind, the most important thing being done today in our training schools. But few hospitals can undertake such a preparatory course, and favored institutions like the Glasgow Royal Infirmary, the London Hospital, and the Johns Hopkins, are to be regarded, as it seems to me, as experiment stations, where object lessons may be studied by the rest of the hospital world, to be adapted to other conditions, and carried on in central schools such as the Dublin Metropolitan Technical School for Nurses. This latter idea has been suggested by several of our superintendents.

The Dissimilarities In Our Training School. Curricula

Many dissimilarities exist in the arrangement of our curricula of the different schools. Some emphasize one branch and others different ones beyond the rest. But so far from looking upon these dissimilarities as unfortunate, I am inclined to regard them, to a certain extent, as wholesome and indicative of vigorous life. They present, taking

*The Waltham school also gives excellent training of the kind described above as preparatory work ; not, however, separated from the later work of ward nursing in as definite a way, and the New York City and Metropolitan training schools now announce the establishment of six months preparatory training.

them altogether, a set of practical experiments which afford means of critical comparison and enable us to advance more rapidly and intelligently than we could do, were all bound to one method. Where uniformity is needed is in a certain minimum quantity of fundamentals, or what we' might call primary instruction, and to this amount of uniformity we are year by year approaching more closely, as will be seen by examining our training school schedules of work and study. But to require uniformity in the more advanced work would check experimentation, and indeed would be impossible, as our work follows the growth and expansion of medical science and hospital development.

The Hour.S Of Work

Less progress has been made in this direction, on the whole, than in any other. Some half-dozen schools only, so far as I know, have adopted an eight hours' day, and while several have lightened the work to some extent by longer hours off dut}- or by more extended leaves of absence, yet as a rule the long hours are left too nearly what they were, before the addition of the third year, and this seems distinctly wrong, an evident advantage to the hospital not balanced by a corresponding advantage to the pupil ; a demand upon her strength and endurance beyond what is reasonable.

A moderate increase in the outlay made for the training school would allow the enlargement of the nursing staff to the number necessary for reducing the hours of ward work, and the demands of medicine and of the more intelligent part of the public are making it daily more necessary for the nurse to have time allowed her for the cultivation of her mind and heart as well as for manual accomplishment.

The few schools which we have at present working on the eight hour plan do not simply reduce working hours and leave the pupil an unsystematized leisure, but provide the alternatives of physical and intellectual work, with reasonable opportunity for recreation, which make up the ideal life.

The Return Of Private Duty Into The Curriculum

With the extension to the third year there is noticeable a marked tendency to re-introduce the practice of undergraduate pfivate duty, which, in the two years' course, had practically disappeared from all high-grade schools, but which is now returning to an alarming extent. '^

Personally I regard this as a serious danger, and the Society of Superintendents as a body has steadily and invariably opposed it. It is a menace to the graduates and a nullification of the benefits of the third year to the pupil. It means, for her, interruption or entire loss of those opportunities which she can only have in hospital, and which cannot always be compensated to her outside ; she loses the clinical observation and teaching ; loses her class and lecture work or her third year club work ; and what is nearly the most important of all, the daily practice of order, the harmonious subordination of self for a good purpose, the discipline of feeling one's self a part of a symmetrical whole, which does so much to mature and balance the illy-developed and angular though excellent material which ofifers itself in our schools, to be made over into the capable and unselfish woman of good judgment. I present no argument of injustice to the patient in this custom of undergraduate private duty, because, as the patient must always specify that she wants an undergraduate, and as the doctor always knows that the pupil is still in training, there is no question of imposition to the patient, who prefers the pupil nurse because she costs less.

But there is a distinct injustice to the graduate nurse, who is working to support herself and, often, others. She cannot compete with the pupil who, receiving maintenance from the hospital, is sent out at from five to ten dollars a week less than the graduate. Hence we have the anomaly of one and the same school assuming to fit women to earn their livelihood on a certain plane, and at the same time for its own benefit systematically underbidding them in their work; an economic injustice which shows plainly how much we need a knowledsre of related affairs, throueh -ignorance of which one-sided specialists can be a positive hindrance to the general advance of all workers.

There are superintendents of nurses, who, looking at the question only from the standpoint of the education of their pupils, believe that experience in private duty is essential as counteracting the tendency to institutionalism and routine. But so long as the feature of financial benefit to the hospital is present, it is impossible to strip the question of its commercial features and consider it as an educational factor only. And, the charge of institutionalism, of martinet discipline and routinism being made against us, would it not be more sensible not to send the pupil forth from it, into private families, but to bring more of the private patient atmosphere into our wards ; a reasonable amount, and so make the wards less institutional? If all the patients of a free ward could be nursed just a little more nearly as private patients, the nurse could learn her tactful and sympathetic ways from the beginning, and not have so much to unlearn, when she goes into private duty.

Two factors combine today in our hospitals to make nurses mechanical. One is the almost universal understaffing of wards; the result being that the nurse, to get through her day's schedule, can hardly afford to waste even a half minute in unexpected ways; the other is the quite universally (in this country) increasing tendency of hospital internes to limit and restrict nurses to the strict and literal carrying out of " orders " and to a technically perfect attendance upon themselves. I have heard instance after instance proving this repressive tendency deplored by superintendents, who perceive the hedging in of the nurse's initiative with her patient in nursing ways.

The Extension Of Co-Operation In The

Some encoiiragino;- advances are beinj^ made in this direction - much more, however, remains to be done. Some of our most vexations problems would be solved if each lar^S^e school could make itself responsible for the nursing of one or two small and incompletely equipped institutions which are now compelled to conduct their own training schools ; or, if several such hospitals should agree upon maintaining co-operatively a central school which should provide the nursing for all, thus giving one set of pupils a wide and full education, instead of turning out several sets each with a comparatively restricted teaching.* These suggestions, made many times by others, will no doubt in time be utilized in practice.

Miss Chappell : I think graduate nurses all understood, when the three years' course was started, that private duty in the course was abolished. Yet many schools are sending out nurses in the third year, and if the superintendents cannot do away with it entirely we must appeal to our alumnae societies to take up the matter. I think if our associations presented letters on the subject to hospital boards, where this is practiced, that w'e could have something done to put an end to it. I have known of nurses being out for as much as six months, and though I think private nursing is good training I do not think pupils should be sent to wealthy families who are abundantly able to employ a graduate nurse. I know^ many nurses feel strongly on this matter and I am one of them.

*Such an arrangement exists in Washington, where the Children's and the Columbia Hospitals have for some years conducted a training school co-operatively.

Mrs. Robb: So far, the associated alumnae has required two full years of training in the hospital wards, as when it was founded that was the course. The three years' course has developed since then.

Mis Peters : I was trained under a two years' course, and we spent our second year in private nursing. The school now has three years, and the pupils are sent out in the last year. I think it is an injustice to the nurse, who should have the benefit of her third year in training. This matter has been discussed in our alumnae association, and we hope in time to do away with sending out pupils.

Miss Hay : In the school where I was trained the nurses obtain this experience in nursing private patients which is so desirable, without underbidding the graduate nurse. We call it " special duty." The third year nurse has a service in caring for one private patient at a time, in the pay wards. The head nurse is not held responsible for the " special's " work, but the nurse is solely in charge of the patient and is responsible to the doctor, as she would be outside. This gives her the confidence and self-reliance that she needs.

Mrs. Fenwick : Miss Dock's suggestions are so numerous that I shall confine my remarks to two points. First with regard to the all important question, the term of training. When T began nursing twenty-three years ago the generally accepted term was one year: it was gradually extended to two, and in England, during the past decade, it has become almost universal for nurses to be given a three years' course of practical training in the wards, before they are examined finally and certificated. Now we are proving that three years is all too short a time for a nurse to perfect herself in general nursing and in all the specialties, such as maternity and fever nursing, and as the majority of training schools contain no facilities for clinical experience in obstetrics and infectious fever nursing, these special branches must be learnt after graduation. Several of the large London hospitals have extended the term of training to a four years' course. Personally I am in favor of a three year's course in a general hospital, to which special departments are not attached, - a fourth year may thus be usefully employed gaining practical experience in special work, and in the duties of matron, and domestic manager. Nothing under the three years' course can suffice, as after a probationer has learnt the elements of the theory and practice of nursing she requires time to digest and use her knowledge, and become skilled in its performance.

If we appreciate the lessons we have been taught in past ages, we grasp that no good work can be done in a hurry. In the past a long and arduous apprenticeship was compulsory before a man could hope to become a master craftsman, and we have only to compare the artistic value of the handiwork of the long-time apprentice, with the shoddy productions of our own time, to realize the necessity for perseverance before we can hope for perfection.

'Secondly, with regard to the undergraduate nurse being sent out to private duty, I strongly deprecate it - it is absolutely indefensible, it is equally unjust to pupil nurse and patient. It is true that we have not yet defined a standard for a trained nurse and that we do not give a legal guarantee of training to the public, but whether the course be two or three years, it should be completed by the pupil, without interruption, and we should deal honestly with a defenceless public, who would doubtless object to pay high fees for the services of undergraduates, if they knew that their nearest and dearest were placed at their mercy. The system of training private nurses is also important. I am inclined to think the system in England leaves much to be desired. In Canada and the States it is different, and I have been immensely impressed by the fact that the admission of pay patients into all the best hospitals provides a means of educating nurses for private practice in the best possible manner. In attending upon the pay patients in their single rooms, nurses have to perform numerous duties for the sick for which they would not have time in a general ward; moreover, in those hospitals where, in special diet kitchens, the nurses are taught to cook and serve all the food for a refined class of patients, they become conversant with a system which as yet has not been attempted at home. Our nurses go straight out of the general hospital wards, into which only the very poor are admitted, to nurse in private houses, and to wait upon patients of very different habits. It is not surprising that many fail to satisfy the medical officer and the patients' friends. So chaotic are private nursing afifairs in England, that well educated trained nurses are protecting themselves from the competition of the unfit by forming themselves into co-operative societies, each member paying 7|% of her fees to maintain the organization. There is a central office with a telephone, secretaries and other general expenses. A standard of training can thus be enforced, and also if the superintendent is a well qualified nurse, as she ought to be, good discipline amongst the members. Fees are collected for the members and the committee can carefully consider any complaint which may be made against them. I think the future of the private nurse is largely dependent upon commercial co-operation.

Miss Banfield : It may be interesting to you to know that, in looking over the hospital statistics in connection with Miss Peter's remarks, I notice that the hospital board took in between $2,000 and $3,000 in a year for the services of the pupil nurses. This was turned into the general fund of the hospital.

Miss Stewart: In the hospital with which I have the honor to be connected the term of training for nurses is three years, but we bind them to remain four years, that is, for one year after they have obtained their certificate. During- the first three years they are twice examined, and if their practical and theoretic work has been found to be quite satisfactory, they are awarded a certificate of efficiency. In the fourth year they receive payment as fuUy quahfied nurses. The fourth year is spent either in the hospital or on the private nurse's staff. I attach great importance to this last year ; the nurse has up till then had no real responsibility, but now nnich is expected of her, she gets some authority, she is more her own mistress, has more liberty, is less looked after, and learns to stand by herself with some assistance from those who have already learned to walk. In fact she has now time to arrange and estimate her knowledge and experience, and to deepen the channel of her life. The enormous benefit of that year to the nurse is the development of her character, which in many instances the acute observer can see in her expression. Its value to the hospital is also great, as it provides for the continual presence of a fully trained nurse in the wards, the care of the patients is therefore never left, even for a few hours, in the hands of half trained unqualified women.

Miss Stewart : We have in every ward a " Sister " who has been for some years in the service of the hospital ; she is in full charge of the ward, and the certificate nurse is immediately under her in authority. If the sister is out, ill, or for any cause absent from the hospital, the certificated nurse takes her place. If the assistant matron, my secretary, or one of the night superintendents are ofif duty, I take the most capable of those qualified nurses to fill her place, and there is always one nurse assisting in the housekeeping in the nurses' home. In this way they gain much experience which is useful to them later.

Miss Stewart : They are paid $12 a month during the fourth year, which is good pay for a hospital nurse in England. If a nurse remains longer than four years her salary is raised to about $17 a month.

We have a staff of private nurses in connection with the hospital, whose headquarters are in a house near the hospital, but quite apart from it. No nurse is sent out to do private nursing until she has obtained her certificate of three years efficient service in the hospital. When she is not at a case she can live in the home, and is therefore spared the expense of keeping an apartment. She is paid a salary of $12 a month and in addition she has 15% rising to 30% on her earnings.

Miss Hughes : As a representative of one of the large hospitals and training schools, Guy's Hospital, I would like to say that the course of training there is on the same lines as St. Bartholomew's, as described by Aliss Stewart. The nurses are trained for three years, and receive their certificate at the end of that time. The private nursing institution is attached to the hospital, but has quite distinct premises and constitution. It maintains forty-two pupil nurses in training at the hospital, and only supplies the public with fully trained graduate nurses, who receive a fixed salary. The net profit earned in fees by the institution is divided amongst the senior nurses to be applied in the provision of old age pensions.

Miss Stewart: We receive candidates at the age of 21 years on payment of a fee. We also receive free candidates at the age of 23 years. They all have to serve three years before they obtain their certificate, and one year after that, but in the former case the hours are shorter and the work somewhat lighter during the first six months.

Miss Stewart : It is not optional. The candidates sign an agreement before entering the service of the hospital, in which they promise to remain in its service for a period of four years, the fourth year being spent as stafT nurse in the hospital, or on the private stafif of nurses.

Miss Wood : I just want to say a word about preliminary training, going back to the beginning of things. I have seen a very great deal of physical break-down on the part of the nurses, from having the theory and practice carried on simultaneously ; the poor nurse with aching feet and tired muscles, after her hard work in the day, goes into her room, throws herself on her bed, and with her text book endeavors to acquaint herself with the theory. I am down to the ground in accord wdth the argument, that the physiology, hygiene, etc., can be gone through wdth before we go into the wards, and if it was so planned it would make a very great difference. Take the average woman who comes into the hospital and is turned into the ward, what does she know of the language of the hospital, I mean of the use of the technical terms ? She is told to go and bring something; some appliance of some kind, and she rushes off thinking the whole time she only hopes she may bring the right thing. That means mental, physical wear and tear. If before she comes into the hospital wards she has had the various implements pointed out to her and named, when she comes into the ward and is told to go after something, she will go and get it. I do think the present arrangement by which nurses are taught theory and practice at the same time is one of the great reasons for their breaking down.

Speaking from my own experience, (and I stand before you not as a trained nurse, because there was no training in my da}, but we learned from practice, without theory,) I remember quite well when I was first in the hospital being told to put a poultice on the back of the chest. Where on earth was the back of the chest ? I really did not know.

Mrs. Robb: The object in creating the third year of training in this country was intended to be educational and for the benefit of the nurse, but, so far as I can see, to the present time the greater benefit has been to the hospitals. We found that it was utterly impossible in two years to cover a systematic course of training. Some of the subjects were too advanced for the second year, and were obviously third year subjects.

And in addition the hours in the wards were too many and the work too hard to require at the same time a definite course of theoretical study, more time was needed. Therefore when the third year was advocated at our first National Congress, that the nurse should not be required to spend more than eight hours out of the twenty-four in practical work in the hospital, and that a certain portion be devoted to her theoretical instruction, it met with approval, but that feature has not been attained except in two or three instances I am sorry to say, and the same old hours, nine, ten. eleven, and sometimes twelve or even more, are required of our pupil nurses in our hospitals.

Unannounced : I would like to say just one word and that is that I represent a hospital where practically the idea that ]Miss Stewart has presented is upheld. We have been able to do much in the way of shortening nurses' hours, but I have been told repeatedly by the nurses themselves how much they appreciated their third year, and how much they learned in their third year.

]\Iiss Peters : I would like to add that our hospital in connection with its three years' course gives a year's course to the nurses immediately after they graduate, and there is a certificate given at the end of that time, the fourth year. It is not compulsory and they are paid $25 per month. I do not wish to be understood that I disapprove of the three year course, but I do disapprove of sending nurses out. I, myself, was at private duty almost all of the time during my last year, and missed all of the important lectures ; finally I requested to be kept in, and when in I sat up nights, and got up at 4 and 5 o'clock in the morning to study for my examinations.

Miss Early : After hearing so much from so many nurses I feel there is little for me to say, but I would like to advocate the three years' course. I did not have it myself, for the simple reason that my school was small - I had a two years' course ; now I have had seven months' experience as matron, and I feel that the two years is too crowded. We try to get applicants who have had a high school education, and to give them all we can, but a long day's work makes one too tired to study. If it were not for the nursing journals we would fall behind in many things. I have been much impressed and benefited by this Congress.

Miss Barnard : I would request that some of those who have had experiences on the non-payment side of the three year course would relate them.

Mrs. Robb : There are, I think, eight hospitals on the non-payment system. The whole idea was io have a three years' course, eight hours practice in the wards and nonpayment. The whole course was to be on the non-payment basis. In all our old circulars of information we added a paragraph saying, that for the first year seven or nine dollars monthly remuneration would be allowed, and the second year a little less was given, and in the next sentence it read that this was not intended as remuneration, but for text books, uniforms, etc. I could never understand why' less was given the first year when everything had to be supplied. And when I became superintendent it seemed to me better to put the whole thing on an educational basis. The students work for what they get in the way of an education, and they value what they get, but it seems to me no more than fair that the hospital should in return furnish the uniforms and text books for their work. I think if we all look back we can recall how our money was spent each month, how much of it went for uniforms and text books. I do know from my own experience as a pupil that much money was spent on sweets, as we called them, and on good times, but that money was really given to us in trust to spend on uniforms and text books.

Miss Dock : While it seems extravagant to spend much money on cakes and candies we know now that there is a physiological necessity at the bottom of the nurse's craving for sweets. Scientific experiments in feeding armies have shown that soldiers can do more and harder work on a diet of sugar.

Miss Palmer: In my experience as superintendent I have always tried to teach my pupil nurses that the money allowed them by the hospitals for uniforms and text books was to be used first for that purpose. That they must provide themselves with proper uniforms and text books and then if they could save anything they could use it in any way they chose. The hospital should provide nurses with an ample diet, including the sweets needed.

So busy have nurse educationalists been in solving- the problem of correct education for the would-be nurse that, as yet, very little time and thought have been devoted to the more advanced course of instruction by which the woman who is already a graduate nurse may gain additional experience and knowledge in her chosen work.

Some effort, however, has been made in several of the American hospitals to meet this need. A few of the schools, willing to be of further assistance to the nurses to whom they have already given the preliminary training, have attempted to provide post-graduate work for the alumnse. In most instances this has resolved itself into granting such graduates as may wish it the privilege of returning to the hospital for a short period during the school vacation time and of allowing them to take up what work they choose in the wards or operating rooms. Sometimes, in addition, theoretical instruction in the form of lectures has been attempted.

No claim is made by these schools of giving a regular post-graduate course; they are merely attempting to assist their graduates in the only way which ofifers. Undoubtedly this opportunity of again coming into contact with hospital methods and of observing advances in all branches of the work is of great value to the nurse who is fortunate enough to be a graduate of a school sufficiently old, liberal in thought, and strong in finances to allow it to attempt such an undertaking-. As far as it goes it is grood, but it does not go far enough ; is not a permanent educational feature, and reaches only a very limited number of nurses. The schools which are able to undertake even this most simple form of post-graduate work are few in number and fewer still are they which are capable of keeping up this effort year after year, and of continuing to meet the needs of their graduates.

Schools for nurses connected with our modern hospitals, if they carry out the purposes for which they are established - that is, of nursing the sick of the hospital and of educating women to be nurses - do about as much as such institutions with their present limited stafif of teachers can successfully accomplish. If the same teaching force, in a spirit of g-enerous self-sacrifice for the good of the cause, undertakes in addition post-graduate work, without question sooner or later the added strain will be detrimental to the teaching staff, and consequently to the school and to the institution. Should hospital authorities be willing to pay additional salaries and provide extra teachers to carry on this work, the question would assume a different form ; but until such a time arrives it is doubtful whether heads of schools, in justice to their other work, should attempt postgraduate teaching.

Colleges and universities have found it impracticable to deal with pupil and graduate at one time. There are instances on record of the college student making complaint that material necessary for the undergraduate had been utilized for the graduate. These complaints, as a rule, have been listened to and the demands of the students met. Postgraduate work has not been ignored in the several professions, but provision for it is made entirely outside of the ordinary schools of instruction. The same should hold good in nurses' schools. In most hospitals, with proportionately large or small schools attached, and particularly since the three years' course is required, not only the time of the teachers belongs to the school but the material for study and opportunities for experience should be given to the pupil, not to the graduate.

The undoubted spirit of unrest which is sure to accompany the advent of qraduates into a nurses' school is another reason why these schools are not the right places for post-graduate work.

In several of the cities of the United States there are hospitals devoted to specialties, offering post-graduate training in that one branch of the work to any nurse who is a graduate in good standing of an approved nurses' school. These hospitals give from three to nine months' course in practical w'ork, with usually some theoretical instruction. Most of them pay a salary of from ten to fifteen dollars per month, and require the nurse to w-ear the hospital uniform. To the nurse who, having completed the course in her own school, feels that her training has been lacking in certain branches, these courses in special hospitals are of value. It is only a small class of nurses, however, to which these special courses appeal.

The average woman who has graduated from a school giving instruction in all branches of nursing, when she \vishes, for one reason or another, for post-graduate instruction, usually feels the necessity of a general " brush-up." The new methods adopted since her graduation are wdiat the private nurse wants more particularly, while she who has dropped out of the field of actual nursing into executive work realizes her need of an all-round course of study.

In some, if not most, of the post-graduate courses, the graduate, like the pupil, receives her training by doing the entire nursing of the institution. She has practically the same working day - usually nine hours - which she labored through in her training school period. Her work differs from her school w'ork in being of a special nature, but not otherwise ; the same amount of work, if not more, is expected to be accomplished ; there being no probationer, she must scrub basins, clean bath rooms, dust and do other work wdiich in a school the senior nurse is usually relieved of.

It is far from the intention of this paper to criticize post-graduate hospitals and their methods. If these institutions receive graduates for instruction and depend upon them to nurse their patients, naturally the first consideration must be given to the patients and to the accompHshment of the routine duties of the institution. In preference to dirty basins and bath rooms and undusted rooms, the graduate must scrub and clean and dust. But the question to be asked is, " Is the graduate getting what she wants and needs out of post-graduate work ? Has she time and strength to devote to the work now expected from her in a post-graduate hospital ?"

Few women who have completed a two or three years' course in a nurses' school and then devoted from five to fifteen or even more years to nursing are willing or able to make such an expenditure of their strength.

- i\s far as the writer could find, with the exception of the few schools which are attempting to provide for their own, there is no general hospital open to the graduate nurse, so that, even if she would spend time and money and strength, no post-graduate work - in other than the specialties, is available.

If the foregoing statements be true - namely, that nurses' schools cannot undertake post-graduate work, that special post-graduate courses meet the need of a very limited class of nurses, and that no general hospitals are olifering these opportunities - we must acknowledge that in reality there is no post-graduate instruction for nurses in the country. That there is necessity for this instruction and a desire for it felt by nurses in general is beyond dispute. Such being the case, it would seem that something should be done to meet the demand.

As it is nurses who feel this need, and nurses who will be benefited, naturally it must be the nurses tliemselves who will work out the problem and establish such courses of instruction as they wish. The time for depending upon others for every step in the road of progress is long past. Nurses are strongly united now, and thoroughly capable of meeting this demand.

to prepare women to be teachers in nurses' schools. The announcement for 1901-1902 states that " Six students are completing the course for the year 1900-1901, and it is hoped that at least as large a class will be formed for the coming year. Should any nurse of exceptional ability come under your notice, we trust you will place the advantages of the course before her." Further on the report says, " The expenses for the past year were met in part by contributions from many individual superintendents of training schools. Since then no improvement has taken place in the financial condition, and for the coming year there is no present prospect of any other contributions," and so on.

The reasoning which leads up to the following conclusion may be wrong, but it seems to the writer that if this course, instead of being planned for only nurses of " exceptional ability " or for those who wish to be teachers, were arranged to suit all graduates ; if the " hospital economics " course could be made simply a specialty of the whole with another division devoted to practical nursing and new methods, and the whole recognized as post-graduate work, that the present object of training teachers would not suffer. It does not seem unreasonable to predict that large classes of nurses taking up the practical nursing course would assist by their fees very materially to meet the expenses involved.

Should this come to pass, the National Alumnae Association and nurses at large would be interested and feel called upon to assist, and no longer would the financial burden fall on training school superintendents who are unable to bear it indefinitely.

It is beyond the scope of this paper and the ability of the writer to attempt to suggest the desired schedule of instruction. Without doubt, there would be difficulties to overcome ; hospitals would have to be found which would open their doors to graduate nurses on an entirely new basis.

mittee on the Teachers' Course. The object of this paper would be accomplished if it could persuade that committee to consider this matter and if possible enlarge the present undeniably narrow field of work to include all nurses.

If such a thing could be brought about, an inestimable boon would be conferred upon the graduate nurses of the country, and it would seem that the question of postgraduate work would be solved in the most satisfactory manner possible.

Miss Fuller: It is with satisfaction as well as with interest I have noticed that the necessity for the development of post-graduate work is being recognized more and more each year. Most large hospitals now allow their own graduates to return to them for two or three months' ward work.

Certain opportunities are given those who have only had the advantages afiforded them by the training in a small hospital. To illustrate I will give a short outline of postgraduate work as it is conducted at the Woman's Hospital in New York. Here all pupils must be graduates, and they come, as a rule, from small hospitals. The nurses are on duty from seven to seven, with two hours ofif, daily, and one afternoon each week. Classes and lectures are held weekly. Class work consists of systematic instruction in practical nursing, in hygiene, materia medica, anatomy, physiology, and gynecology. A course of lectures is given by the different surgeons ; notes are taken by the pupils, written out, and handed in for correction. A course in massage is also given by a competent masseuse, and one in the diet kitchen under a trained teacher. The whole course is nine months. The pupils spend a definite time in each ward, the treatment room, the operating room, and on night duty. Each ward has a different surgeon, with his own methods, so the nurses have wide experience and gain much in knowledge. Each ward has as head nurse a graduate of some large general hospital. The operating room is also in charge of a permanent head nurse. The surgical technique is quite perfect, and the pupils' course includes every detail, including the after-care of operative cases, who are placed, two each, in cottages on the hospital grounds. As a rule, one nurse cares for two patients, by day, and another by night ; serious cases have a special. One head nurse superintends the cottages and teaches the nurses.

The pupils receive $15 per month, with board and laundry. At the end of their service they must pass a satisfactory examination before the medical board, before receiving the diploma of the hospital. It was most interesting to note the development of many imperfectly taught nurses under this training. It is an excellent experience for any graduate, wherever trained. It broadens one, and I look back upon the months spent there as well spent.

The President : The next paper we will take up is on nursing the insane, by Miss Laird, Superintendent of Nursing, State Hospital for the Insane, Seneca County, New York.

S. Louise Laird

The history of the insane from earliest times to the present day presents strange contrasts of ill-treatment and favor. Among- the Mohammedans it was believed that they were the blessed of God, and that their souls were removed early as a mark of partiality. The Orientals regarded their ravings as inspirations, and they were treated with marked respect and kindness ; even among the Indians the feebleminded and insane received kind treatment. But throughout Christendom for long ages they were thought to be accursed and possessed of devils, and were treated accordingly. So we find these afflicted people, miserable because of their mental condition, made infinitely more wretched by being chained for years to the walls of dark and solitary cells, or made to subsist on bread and water, or lie on beds of straw, tortured, whipped, occasionally burned or executed, - always the victims of a fixed belief that insanity was an incurable malady.

In the latter part of the eighteenth century Pinel in France and William Tuke in England became, with others whose names are less known, but who are doubtless as worthy of being immortalized, pioneers in advancing the theory that the insane were human beings afflicted with disease, and gradually the idea that these people were unfortunate and not criminal began to prevail, and the places where they were confined to assume the character of asylums

Dorothea Dix began her great work in the first half of the nineteenth century, and the degree of comfort and care that the insane of America now experience is largely the outgrowth of her zeal and energy. While our present methods are doubtless the best that have existed in this country, still they could be improved in many ways, particularly in the care given the indigent insane. The establishment of training schools in our State hospitals is a great step in the right direction, the object being to secure for these afflicted people more intelligent and scientific treatment, and surely they need all the help that can be given them, and by as skillful and enlightened nurses as can be obtained.

Insanity is defined as " a prolonged departure from the individual's normal standard of thinking, feeling, and acting," and allows of many different classifications. For practical application of the manner of nursing we will consider it from three great divisions :

In this brief paper we will give more time to the first two classes, as they are the cases which you as graduate nurses will meet, and who require more intelligent and scientific nursing than the third class, as they need but little more than custodial care or the attention given any feeble patient.

" Mania is a form of insanity characterized by emotional exaltation, acceleration of the flow of ideas, and motor agitation.'' These cases are very interesting, as about seventy per cent, of them are recoverable, which is always a source of inspiration to the nurse, and a needed one, as their care is extremely wearisome during the excited period. The pathological cause for this disorder is as yet much obscured, careful investigation revealing no anatomical basis, though a theory prevails that it is due to a congestion in the higher brain-cells. Perhaps the belief in another theory, that there is a lack of nutrition in the nerve-cells, producing this unnatural condition, is the best for a nurse, as then she will be stimulated to persevere in feeding her patient, which is regarded as one of the chief agents in bringing about a recovery.

Usually a maniacal outburst is preceded by a period of depression, which may continue for a few days or for a longer time, possibly several months, and when this gives way the true disorder begins to manifest itself and the patient becomes noisy, restless, incoherent, and lacking in self-control. The entire system is disordered, the skin being hot, the tongue dry and coated, sometimes to a great degree, the lips often parched and bleeding, the bowels irregular, the urine scanty, the sleep disturbed and fitful.

As there is usually no distaste for food, there may be no difficulty in giving it, but again it may have to be administered forcibly, as the patient's mind is too exalted and preoccupied to know if he has eaten or not. Simple liquid foods are recommended to be given frequently and in as large quantities as possible, even to the point of overfeeding. Rest in bed with treatment in massage is urged if the patient is not too resistive.

Sleep may be induced by warm baths or hot wet packs, though occasionally a sleep-producing agent will be necessary. In some cases there is much danger from overexhaustion, but if food be given in sufficient quantities and is assimilated this result may be averted. As much care should be given the hair, teeth, and mouth of the patient as if he were suffering from a fever delirium, and this will add greatly to his comfort and appreciation on recovery. There is but little danger of suicide in maniacal cases.

As to his moral treatment, there is no use in arguing with him in regard to his delusions, though these may be gently but firmly contradicted or else disregarded, and while it is best in the acute stages never to discuss these halkicinations and delusions, still they should not be acted upon or agreed with. During convalescence brief but positive denials of the imaginings of the patient may be beneficial, but it should always be done in the kindest spirit and manner. As the patient improves there will be a gradual subsidence of this exalted state towards the normal condition, possibly accompanied by a " tearful irritability," and gradually the mental balance will be restored. There are instances where this restoration takes place very suddenly upon awakening from a normal sleep, but this is not usual.

The course of an attack of acute mania usually extends over a period of from three to six months, though some cases appear to run their course in a much shorter time. Occasionally this disorder takes the form of an inflammatory condition of the brain, in which all the before-mentioned symptoms will be greatly intensified and death may result from exhaustion. More frequently death is the result of some complication, as nephritis or pneumonia. About five per cent, of these cases die and ten per cent, result in dementia. Seventy-five per cent, show hereditary taint, which, while it is not considered an essential factor in producing mental disorders, is regarded as rendering the nervous organism unstable, and therefore more liable to collapse when it meets any severe strain, either physical or mental.

Cases of chronic mania are very rare, and consist of a continuance of maniacal disturbances, extending over a long period, perhaps for years. As a rule, the physical condition of the patient will remain good, the mental state one of elation, and reason and judgment will be much impaired. There is no tendency to suicide and the habits may be most untidy. Recovery from chronic mania is very unusual.

The second class of insane which we will consider are cases of mental depression or of melancholia. This form of insanity is characterized by " constant depression, retarded flow of thought, and fixed delusions." These are certainly the most miserable of all that great body of people. Some sit for days with drooping figures and sad faces, absorbed by the contemplation of their own misery, beheving most firmly that they have committed an unpardonable sin, or that they are responsible for the sins of the world, or that they have brought want and trouble upon their families. Others constantly walk about, moaning and wringing their hands, while still others complain they have no feeling at all, seeming unable to appreciate any sensation of either pain or pleasure. When hallucinations are present they are of a depressing and terrifying nature, and the patient is often troubled by " hearing voices " which constantly reprove or threaten him.