918 HELP FROM NURSES The long-term solution must be to reinforce general practitioners with nurses, even if this means reducing the number of nurses in hospitals ; if the practitioner were enabled to do his’ work properly, far fewer patients would need hospital nursing. Possibly in future there will be devolution of work not necessarily requiring a doctor’s care to suitably trained nurses, working in close collaboration with doctors, as in industrial medicine. It would be an advantage if nurses engaged on this work could have some secretarial training ; and they should also be empowered to sign many of the docnrnents which are ’at present valid only when signed by the doctor himself. The procedure might be as follows. All new patients would be seen by the doctor, along with those told to see him on that day ; and the nurse would see and attend to patients who had been told to report to her for a dressing, an injection, or, in the case of protracted illness, a repeat certificate. The nurse would refer back to the doctor any patient of whose progress she was in doubt, and other patients at intervals decided by the doctor. He would also see all patients for their final certificate on discharge. Similarly, the nurse, if provided with means of trans- port, could lighten the doctor’s visiting-list. The doctor, having answered all first calls, would delegate certain visits to the nurse, perhaps to give penicillin or to check an evening temperature ; and some elderly patients who might otherwise remain unvisited could be added to the nurse’s list for more or less routine visits, the doctor being kept informed of any change in the patients’ condition. Though highly desirable, it would be economi- cally unsound for practitioners to have the full-time help of a nurse; unless their lists were large ; and then the work done by a suitable nurse might obviate the need for a medically qualified assistant, who would be released for independent practice elsewhere. The nurse who is to’ assist the practitioner-much in the way that the houseman aids the specialist-would need to be selected from among those who are experienced and able to accept responsibilitv.- Experience of district nursing should be an essential preliminary, and the existing home-nursing service should be retained as a training medium for these " general-practitioner nurses," and also as an aid to doctors whose lists do not warrant the employment of a full-time worker. After a stipulated period " on the district," the nurse would be apprenticed to an individual doctor or a health-centre team, and thereafter she would sit for an examination comparable to that for the diploma in industrial nursing ; by passing this examination she would qualify as a " general nursing practitioner," with improved status. Such a qualification might empower the holder to sign statutory certificates in her own right. It might also lead to the acceptance in a court of law of her testimony as that of an expert witness, thereby raising her status further in the eyes of her colleagues. Her value would be greatest in the home, where the need for education of the patient is greatest. In time, perhaps, patients would recognise her as the first person to consult on minor ailments. , , c, AIDS TO DIAGNOSIS Whether working single-handed or with a general nursing practitioner, the doctor cannot give of his best if lie is denied the diagnostic and therapeutic facilities whose use he mastered as a student. During the year under review, 19% of all patients referred to hospital were sent to a. casualty department ; and the reason was lack of facilities and time. In the same way some patients were referred to consultants because only they could order the investigations needed to establish a diagnosis which otherwise could have been made in the surgery. The remedy here would seem to be adequate radiological and pathological equipment of the new health oentres ; for it is doubtful whether the existing laboratory services could meet the demands of the many frustrated practitioners who are now forced to send their patients to specialists even to obtain a blood-count. In advance of health centres, small subsidiary laboratory and X-ray units might be set up in thickly populated and under-doctored areas. The pracstitioner’s experience in sharing such a. diagnostic unit with his colleagues might stand him in good stead when later they met at the health centre itself. In the long run it might be well to include in health centres a ward annexe where the general practitioner could have charge of a, few beds of his own. In such an annexe, which would be lightly staffed, the general prac- titioner would undertake the preliminary investigation of his own patients, with the help of the centre’s radio- logical and pathological departments. Visits from hospital consultants would afford miniature refresher courses and bridge the gap between specialist and practitioner. At present the practitioner is unable to offer the best service of which he is capable. A little breeze is beginning to blow through the valley of dry bones that is general practice. Our aim should be to fan this into a tempest about the ears of the administrators in whose hands practitioners placed themselves on July 5, 1948. Special Articles HISTORY OF NURSING (FROM A CORRESPONDENT) GREAT advances have taken place in nursing in the last ninety years. The Nightingale impetus has enabled the profession to meet the demands of a rapidly expanding hospital system in Great Britain and in Northern Europe, and in a rather different form in America. Its influence has spread through the older Continental systems and to a large extent drawn them into its own pattern. This country is proud of its central position in this world-wide movement, and in her General History of Nursing, a- second edition of which has recently been published,! Mrs. Seymer quite properly reflects this sense of achieve- ment. As one turns the pages one feels the onward march -the first training schools, the first attempts at organisa- tion on a national basis, and the culmination (in Great Britain) of State registration in 1919, itself the starting- point of a series of similar enactments all over the world in ever-widening circles. On and on ; how hospital nursing has been adapted to the various branches of public-health work ; how the nurses rose to further heights under the stress of war ; how there are now even paratroop nurses-here all is set out with much interesting detail and pleasant illustrations. Many, however, are conscious today,.as they were not twenty or thirty years ago, that behind this sense of achievement there is ground for anxiety. The rise in numbers has not been accompanied, it is whispered, by a rise in the quality of the nurses or of nursing ; there has even, despite all the forward movement, been a real shortcoming. Apart from the numerical difficulty, the ideal that seemed within our grasp in the ’20s has not been realised in its fullness. There has been criticism from outside, and attempts by working parties and others to offer solutions, but the keys offered have rattled in the lock. What light can history throw on all this ’? It is here that the standard histories, of which Mrs. Seyner’s is the most notable example, fail us. The history of nursing has not yet passed out of the stage of 1. A General History of Nursing. (2nd ed.). By L. R. SEYMER, M.A. Oxfd, S.R.N. London : Faber & Faber. Pp. 317. 21s.
Transcript
918
HELP FROM NURSES
The long-term solution must be to reinforce generalpractitioners with nurses, even if this means reducingthe number of nurses in hospitals ; if the practitionerwere enabled to do his’ work properly, far fewer patientswould need hospital nursing. Possibly in future therewill be devolution of work not necessarily requiring adoctor’s care to suitably trained nurses, working in closecollaboration with doctors, as in industrial medicine.It would be an advantage if nurses engaged on thiswork could have some secretarial training ; and theyshould also be empowered to sign many of the docnrnentswhich are ’at present valid only when signed by thedoctor himself.The procedure might be as follows. All new patients
would be seen by the doctor, along with those told tosee him on that day ; and the nurse would see andattend to patients who had been told to report to herfor a dressing, an injection, or, in the case of protractedillness, a repeat certificate. The nurse would refer backto the doctor any patient of whose progress she was indoubt, and other patients at intervals decided by thedoctor. He would also see all patients for their finalcertificate on discharge.
Similarly, the nurse, if provided with means of trans-port, could lighten the doctor’s visiting-list. The doctor,having answered all first calls, would delegate certainvisits to the nurse, perhaps to give penicillin or to checkan evening temperature ; and some elderly patientswho might otherwise remain unvisited could be addedto the nurse’s list for more or less routine visits, thedoctor being kept informed of any change in the patients’condition. Though highly desirable, it would be economi-cally unsound for practitioners to have the full-timehelp of a nurse; unless their lists were large ; and thenthe work done by a suitable nurse might obviate theneed for a medically qualified assistant, who would bereleased for independent practice elsewhere.
The nurse who is to’ assist the practitioner-much inthe way that the houseman aids the specialist-wouldneed to be selected from among those who are experiencedand able to accept responsibilitv.- Experience of districtnursing should be an essential preliminary, and the
existing home-nursing service should be retained as atraining medium for these " general-practitioner nurses,"and also as an aid to doctors whose lists do not warrantthe employment of a full-time worker.After a stipulated period
" on the district," the nurse
would be apprenticed to an individual doctor or a
health-centre team, and thereafter she would sit for anexamination comparable to that for the diploma inindustrial nursing ; by passing this examination shewould qualify as a " general nursing practitioner," withimproved status. Such a qualification might empowerthe holder to sign statutory certificates in her own right.It might also lead to the acceptance in a court of lawof her testimony as that of an expert witness, therebyraising her status further in the eyes of her colleagues.Her value would be greatest in the home, where the
need for education of the patient is greatest. In time,perhaps, patients would recognise her as the first personto consult on minor ailments.
, , c,
AIDS TO DIAGNOSIS
Whether working single-handed or with a generalnursing practitioner, the doctor cannot give of his bestif lie is denied the diagnostic and therapeutic facilitieswhose use he mastered as a student. During the yearunder review, 19% of all patients referred to hospitalwere sent to a. casualty department ; and the reasonwas lack of facilities and time. In the same way some
patients were referred to consultants because only theycould order the investigations needed to establish adiagnosis which otherwise could have been made in the
surgery. The remedy here would seem to be adequateradiological and pathological equipment of the newhealth oentres ; for it is doubtful whether the existinglaboratory services could meet the demands of the manyfrustrated practitioners who are now forced to sendtheir patients to specialists even to obtain a blood-count.In advance of health centres, small subsidiary laboratoryand X-ray units might be set up in thickly populatedand under-doctored areas. The pracstitioner’s experiencein sharing such a. diagnostic unit with his colleaguesmight stand him in good stead when later they met atthe health centre itself.
In the long run it might be well to include in healthcentres a ward annexe where the general practitionercould have charge of a, few beds of his own. In such anannexe, which would be lightly staffed, the general prac-titioner would undertake the preliminary investigationof his own patients, with the help of the centre’s radio-logical and pathological departments. Visits from
hospital consultants would afford miniature refreshercourses and bridge the gap between specialist and
practitioner.At present the practitioner is unable to offer the
best service of which he is capable. A little breeze isbeginning to blow through the valley of dry bones thatis general practice. Our aim should be to fan this intoa tempest about the ears of the administrators in whosehands practitioners placed themselves on July 5, 1948.
Special Articles
HISTORY OF NURSING
(FROM A CORRESPONDENT)GREAT advances have taken place in nursing in the
last ninety years. The Nightingale impetus has enabledthe profession to meet the demands of a rapidly expandinghospital system in Great Britain and in Northern Europe,and in a rather different form in America. Its influencehas spread through the older Continental systems andto a large extent drawn them into its own pattern. This
country is proud of its central position in this world-widemovement, and in her General History of Nursing, a-
second edition of which has recently been published,!Mrs. Seymer quite properly reflects this sense of achieve-ment. As one turns the pages one feels the onward march-the first training schools, the first attempts at organisa-tion on a national basis, and the culmination (in GreatBritain) of State registration in 1919, itself the starting-point of a series of similar enactments all over the worldin ever-widening circles. On and on ; how hospitalnursing has been adapted to the various branches ofpublic-health work ; how the nurses rose to further
heights under the stress of war ; how there are noweven paratroop nurses-here all is set out with much
interesting detail and pleasant illustrations.Many, however, are conscious today,.as they were not
twenty or thirty years ago, that behind this sense ofachievement there is ground for anxiety. The rise innumbers has not been accompanied, it is whispered, bya rise in the quality of the nurses or of nursing ; therehas even, despite all the forward movement, been a realshortcoming. Apart from the numerical difficulty, theideal that seemed within our grasp in the ’20s hasnot been realised in its fullness. There has been criticismfrom outside, and attempts by working parties and othersto offer solutions, but the keys offered have rattled in thelock. What light can history throw on all this ’?
It is here that the standard histories, of which Mrs.Seyner’s is the most notable example, fail us. The
history of nursing has not yet passed out of the stage of
1. A General History of Nursing. (2nd ed.). By L. R. SEYMER,M.A. Oxfd, S.R.N. London : Faber & Faber. Pp. 317. 21s.
919
the chronicle into that of critical history. "
Today,"said Maitland, " we study the day before yesterday, inorder that yesterday may not paralyse tomorrow." Forsuch guidance we turn to Mrs. Seymer largely in vain.Is it possible, we must ask, to get below the surface andanalyse the mistakes which have been made in yearsgone by, and to relate the history of nursing intelligiblyto the social history of ourtimes If we could get thehistory right, we might be within sight of finding real andnot pseudo-solutions to our problems.
THE STATE EXAMINATION
Here we cannot hope to do more than look for pointers :let us try to test the matter by one or two examples. Itis a defect in most of the accounts to be found on theshelves of a hospital library that the case against Stateregistration by State examination is glossed over. It is
coming to be forgotten by the younger generation thatthere is a possible alternative course backed by no lessan authority than Miss Nightingale herself. We haveto remind ourselves that her opposition extended to thewhole conception of examination-" you cannot selectthe good from the inferior by any test or system ofexamination." The much-vaunted " Register
" wouldnot, she thought, raise the profession of nursing ; itwould do- an injury to the better nurses by putting themon a level with the inferior, and to the profession bystereotyping a minimum standard. We have to remindourselves too that here and there today there are to befound good judges who hold the same view.How is the matter handled in this most widely read and
most authoritative of the histories of nursing ? Q Mrs.
Seymer is too honest to pass without notice the longopposition to State registration, and she duly notes that" on no other subject in all nursing history has suchcontroversy raged or such acrimonious discussion takenplace but she quickly makes up her mind and proceedsto set out the " basic principles which lie behind allState interference " ; to wit, " that on the one side thegraduate nurse has a right to have her professional status,and interests legally safeguarded, and on the other thatthe public ought to be protected against the semi-trained or untrained woman." On these questionablefoundations she builds up the case for State registration,and the reader is referred to other sources for the viewsof the antiregistrationists.Now here surely was matter for the most serious critical
discussion ; how far, in the light of subsequent events,was Miss Nightingale right, and how far was she wrong 1Is it not at least arguable that she was more right thanwrong ; that a very small dose of State control-i.e.,the inspection and approval of training schools-wouldhave proved the better plan and have avoided most ofthe troubles under which we now labour ? Impossible,says the nursing world with almost one voice ; but isthis not possibly because it has been led to think so bya selective presentation of the historical background ? 1’The group of ideas which carried the day in 1919 owedmuch to assimilation from non-nursing sources and wasclosely bound up with the movement for political emanci-pation for women. They have usurped the place of theNightingale tradition in our historic perspective. Let usat least be clear that State examinations and " studentstatus " itself-as contrasted with apprenticeship-haveno claim to be considered part of the Nightingaletradition.
CURRICULA
Let us try a different tack. Speaking generally themedical profession has for many a year been critical ofthe amount of book-learning required of a nurse. AnAmerican doctor, writing as long ago as 1912, speaks ofthe modern curriculum which " not one pupil in a hundredin the training schools " can possibly master. " The
builders of these curricula feel within themselves thatthe training schools are not up to modern demands[i.e., those of 1912] and they are attempting to correctthis fault by setting up courses of study that would fillthe want, but their pupils cannot measure up to them."How modern this sounds ! Now the General History ofNursing is silent about this persistent difference of
opinion ; it is not even mentioned that in Great Britainthe proportion of failures in the State examinations hasoften been high and has been the cause of concern, andthis at a time when the numerical shortage was itself alsoserious. Of entrants who survive the preliminary trainingschools about 30% fail annually in the preliminary Stateexamination and some 20% fail in part II or in the final.The total of those eliminated from continuing in nursingby examinations thus amounts to 44%. They canbecome assistant nurses, but that is another matter.’The deterrent effect of these failures on recruitment tothe profession can be well imagined.
Of course there is much to be said for at least sometheoretical instruction ; but the fact of this long-standingdifference of opinion is passed over by Mrs. Seymer. Itwould not be fair to criticise her on this account, for sheis but reflecting a very general attitude. But we mustask what sort of a history is it that can close its eyes inthis way when it chooses Is it well that those who,in a decade or more hence, will be our legislators onthe General Nursing Council should get their historyfrom sources which leave such large questions as thisundiscussed ?
THE AMERICAN SYSTEM
Or let us look across the water and see what has been
happening in America. It is one of the merits of the bookthat it sets out plainly the distinguishing features offour systems of nursing organisation : the Nightingalesystem, the American system, the Motherhouse system,and the Continental system.
In earlier days the American system differed from theNightingale rather in detail than in principle. The
position of the matronis different, and corresponds to adifferent type of internal organisation in the hospital ;but the apprenticeship principle was common to thetwo systems. What is important for the historian israther the point at which the American tradition beganseriously to diverge from our own. This it did when ityielded pride of place to the schools run on universitylines, thereby abandoning the apprenticeship principle.Here surely is rich material for the historian ; the new
approach was already in full swing by the time of theGoldmark report in the ’20s.Much information has been brought back to this country
by nurse visitors who have inquired pretty closely intothe results of the system ; they have found caase foranxiety about what is happening across the Atlantic. It -is certainly of great importance for our own future thatthe end-results of a system superficially so attractiveshould be properly assessed. Does it not mean that thebulk of bedside nursing gets delegated to a secondarygrade of nurse ? Are we right, or are we wrong in seeingthe multiplication of university schools on the Americanmodel in other parts of the world as a not unmixedblessing ? Mrs. Seymer is content to record the approachtowards the university as though it were but another
step on towards the ultimate goal : "on the wholeconnections between training schools and universitiesseem to be multiplying and their cooperation in theteaching of nurses will doubtless be of increasing value."One would feel happier if this advance were chronicledwith a more critical pen. The story of nursing since
‘
Florence Nightingale cannot be told intelligently withouta grasp of the developments which have been going onin the outer world, and an assessment of the mannerin which they have obtruded themselves into the handling
920
of nursing questions. A good example of such is theover development of university-ism in America, and itseffects upon nursing in the American hospitals. It is sadthat it should be accepted uncritically over here.
OPPORTUNITY
We in Britain have now an opportunity unparalleledin the history of nursing. We have the better elementsof the old tradition still with us, and we are now aboutto reverse one, if not both, of the two great mistakesmade thirty years ago. Nursing education was thentidied up without the .provision of educational funds,and thereby to a large extent stultified : and a singleState examination was adopted with scarce a thoughtgiven to the alternative policy of control through thetraining schools. Within the framework of the newAct we have the power to embark upon experiments.Are our minds sufficiently clear to make good use ofthis opportunity ? Or is our whole conception of what isopen to us so choked by a firm belief in progress since1919 that we cannot see that we may have to retraceour steps before we can advance ? ‘
THE WORLD’S HEALTH
AT the opening of the third World Health Assembly,at Geneva last Monday, Dr. Brock Chisholm, director-general of W.H.O., criticised governments for failing todevote enough of their resources to health services." What is lacking and what is urgently needed is a greaterdetermination on the part of all national administrationsto expand the health services of their countries and thusraise the health standards of their populations ..."The Organisation has itself been in difficulties through
failure of governments to pay their contributions. Ofthe 1948 budget, 15-5% is still outstanding, and in 1949it was necessary to defer final settlement of a loan fromthe United Nations and to draw on a special UNRRAfund. As it was, expenditure was restricted to$5 million.This first full year of activities is described by Dr.Chisholm in his annual report,l issued last week. Theyear was marked by progressive decentralisation of theOrganisation’s work ; by the end of the year regionaloffices were functioning in Alexandria for the EasternMediterranean region and in New Delhi for the South-East Asia region, while the Pan American SanitaryBureau in Washington is now serving as the regionaloffice for the Americas, as the first step towards inte-gration of the bureau with W.H.O. A special officewas set up for Europe to pave the way for the creationof a regional office in this area.The former practice of sending field missions to
countries has been discontinued ; field operations arenow carried out, instead, by demonstration teams andshort-term consultants. During the year the Organisationconcerned itself with only a small number of specialfields, such as the control of malaria, tuberculosis, andvenereal diseases, and the more general programmesdeveloped more slowly. Among the work carried outby the technical services has been the completion of theInternational Pharmaeopmia (announced last month) ;the sixth revision of the International Lists of Diseases,Injuries, and Causes of Death ; expansion of the
epidemiological warning system ; and progress towardsrevision of the International Sanitary Conventions.
Cooperation with other bodies is growing. Thus it is
expected that this year funds made available under theUnited Nations programme of technical assistance for
economic development will allow of extension of theservices to underdeveloped ar with intensification1. Official Records of the World Health Organisation, no. 24 :
Annual Report of the Director-General to the World HealthAssembly and to the United Nations, 1949. Geneva. Pp. 113. 6s.
of health programmes essential for the rehabilitation ofagricultural and industrial workers ; and last week it wasannounced that LTNICEF was to set aside nearly$6 millionto be spent, in conjunction with W.11.0., on improvinghealth conditions in various Asiatic countries.
Dr. Marcolino Gomez Candau (Brazil) has been appointedto the directorship of the division of organisation of public-health services. Dr. Victor Sutter (San Salvador) has beenplaced in charge of the division of communicable diseasesservices.
HOSPITAL ADMINISTRATIONPRONOUNCEMENT BY MINISTER
THREE new developments in the administration of thehospital service were announced by Mr. Aneurin Bevan,Minister of Health, when he addressed the annualconference of the Institute of Hospital Administrators,in London on May 5.
Mr. Bevan is reported by the Press Association as.
saying that a uniform system of hospital accounting-which he hoped they would soon be getting-wouldpave the way to a system of comparative costing." This system of comparative costing will show the red-light," he said, " and it will be our duty to find outwhy costs are higher in gross, or higher under any par-ticular heading, in some hospitals. Then the investigationstarts." Some of the voluntary hospitals appeared tohave had an extraordinary system of non-accountancy,because the Ministry had not been able to discover howthey added up or subtracted.
" Further we propose to have-because hospitals varyso much in ages and in their specialties-to have acompetent team not consisting only of administrativeofficials but also men of medical knowledge and withknowledge of hospital administration to visit hospitals.They will establish after an examination on the spotan agreed staff ceiling. After that has been agreed onit will not be possible to exceed that ceiling withoutconsent."
The third development mentioned by Mr. Bevan wasan investigation
"
to find out whether it is possible tohave a unit system of costing so that we can have amore refined check still." The Nuffield Trust and KingEdward’s Hospital Fund were helping towards that end.
ESTIMATES
Mr. Bevan continued : " I have given a pledge for1950-51 that there will be no exceeding the financialceiling that has been laid down in the estimates. A lotof foolish things have been said about the SupplementaryEstimates, and they have been regarded by some peopleas pieces of self-evident evidence that the finances ofthe National Health Service were not under effectivecontrol. That is a very silly thing to say because it isnot until at least one year’s experience has been obtainedthat it has been possible to find out what the expenseswould be.... Now our estimates are based on muchsurer foundations."
" Now " said Mr. Bevan, " we have to show that ouradministrative machinery is sufficiently gripping toenable us to say with some degree of predictability whatthe Health Service is likely to cost. Therefore we musthave economies in order to have expansions. If theHealth Service is to live within its estimates any improve-ment in any particular part of the service must necessarilycome out of the economies in some other part. Nextyear is an exceedingly important one. If at the endof it we can say-and I am sure we shall-that thisvast apparatus is entirely within our management andcontrol we shall have won the most important battle inthe development of the service."
