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There is something in the dry yet intoxicating atmosphere, both physical and mental, of the United States that stimulates the reforming spirit, which occupies itself not only with the States themselves but with other countries less favoured both in climate and social conditions. With the aid of the vast sums of money provided by the Rockefeller Trust, its directors are able not only to carry on investigations and crusades in the New World to an extent hitherto deemed impossible in the more lethargic Old World, but actually to extend their activities to all the quarters of the globe, in the hope of making the whole universe a place fit for Americans to live in and to be satisfied with. Hence the Rockefeller Foundation is familiar to the well-informed of all countries as a patron of research, an organizer of investigations, and a munificent benefactor to those who may persuade the almoners of this great trust that their work is valuable.

For this reason any volume which appears before the world with the imprimatur of the Rockefeller Foundation is bound to be read and received with serious attention and anxious

(1) Nursing and Nursing Education in the United States. Report of the Committee for the Study of Nursing Education. 1923. New York. The Macmillan Company.

(1)

consideration. The report under review, dealing with a problem long familiar to the United States and England, and of pressing importance in other countries where the nursing of the sick is not yet highly organized, should be and will be read by everyone, in every country, who is interested in the development and progress of the profession of nursing.

But a word of warning must be uttered lest the recommendations of the Rockefeller Committee be taken as applicable to every hospital in every country, however primitive. The old parable as to the putting of new wine into old bottles is still apt, and there is a very great danger that the new wine of the Rockefeller Foundation may burst the bottles in many a country of Eastern or even Western Europe, if poured in too rapidly. With this warning let us review the main conclusions arrived at by the Committee.

PRELIMINARY EDUCATION

The Committee think it should be laid down as a general principle that every training school should require that all applicants for admission should have taken a full high school course of training; and it distresses them to note that there has been a striking decrease between 1911 and 1918 in the number of training schools

in the United States requiring the full high school course before entrance. The percentage fell from 40.6 in 1911 to 28.1 in 1918.

It may be said at once that even in England it is impracticable to require a full high school course from every applicant. To do so would merely result in an insufficient supply of nurses. As nursing service in hospitals in England is still voluntary, one must take the best applicants one can get, and it is difficult to see how one is to obtain a higher standard of preliminary education except by the cooperation of high school head mistresses and by propaganda in schools in support of nursing as a profession. And head mistresses rightly say that it is difficult for them to help the hospitals to any appreciable extent as long as there is any considerable interval between the age for leaving school and the age for entering a hospital; for in this interval the girls pass out of the sphere of influence of the head mistress and take up some other occupation or profession.

HOSPITAL TRAINING

The Committee is strongly opposed to the existing "apprenticeship" system of training nurses. It is stated that:

"Gradually it has become apparent that the old system is a slow and cumbrous method of education; that it often has not even the virtues of a true apprenticeship wherein pupils work directly under the eye of a master. For in the hospital ward the immediate superior of the new student is the head nurse, responsible for the management of the ward unit, large or small, according to circumstances. Her duties are principally executive; as a teacher she is rarely equipped. With the best teaching equipment, she must in any case, after satisfying the imperative claims of ward management, have but the scantiest margin of time or attention available for the students. Often, indeed, she is herself a student learning administration, the practical running of a ward with its countless details as to supplies, assignment of nurses, household management, etc."

The remedy suggested is that the hospitals to which training schools are attached should be staffed almost entirely by trained women and that the probationer nurses should enter the wards on much the same footing as medical students; to be taught, but not to do the work. And the trained nurses are to be relieved of most of their routine work by the introduction of a lower grade of nurse, or nursing worker, a child of Gibeon, who shall hew the wood and draw the water while the trained nurse does the really useful things.

The main objection of the Committee to the present system of nursing training is that it involves routine duties, and these are abhorrent to the Committee.

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One may say at once that cleaning vegetables and cooking for the wards is not done by the nurses in English hospitals, but by the kitchen or domestic staff, but there are many routine duties which must be carried out daily by nurses both while in training and in private practice; and routine is not only a valuable

factor in education, but a most valuable assistance to intellectual development. One must be always thinking. In this connexion it may be permissible to quote from Professor A. N. Whitehead, one of the most distinguished mathematicians and philosophers in England, who is shortly going to the University of Harvard as Professor of Philosophy :

"It is a profoundly erroneous truism, repeated by all copy books and by eminent people when they are making speeches, that we should

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The curriculum is to be intensified and shortened by the reduction of the present three years to two. The Committee states :

"In our opinion the reduction of the present three-years' course is of the first importance both in order to aid in meeting the increased demands for nursing service of all kinds in all parts of the country, and to aid in recruiting students who may well hesitate to devote three years to a training to which they may be willing and able to give a shorter period of time. The three-years' course not only should be radically reduced by about one-fourth, but can, in our opinion, be so reduced to the advantage of training.'

The curriculum suggested is given below:

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632

32

24

Hours

45

15

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On reading this through I feel like the Harvard student, who, after one of his courses of intensive study, was asked what he thought about it "Well, Doc!" he said, "I feel just numb".

(1) In addition to instruction in the preliminary term, additional hours in nursing procedures are planned for the summer term.

(2) In addition see under Dispensary.

As a curriculum for a woman doctor it is inadequate; for a nurse it is excessive and superfluous. The Committee appears to look upon a nurse as a person to be trained to become a sort of doctor's assistant. This is not her function. Her duty is to carry out accurately the instructions of the doctor as to the nursing of the patient; it is not her duty to assist in treating the patient. The argument that she should be in a position to understand all that the doctor is doing and ordering is fallacious. To do so she would have to have a full medical education, and become a doctor herself.

A curriculum such as that outlined, though it looks well on paper, will fail in practice. What the nurse will be taught will be beyond her powers to absorb in the time allotted, and she will only get a dangerous smattering of many subjects which she cannot thoroughly grasp. It is far better that she should accept a more modest programme and learn it thoroughly.

I have read this important volume carefully through from cover to cover; but I must say that I am not as yet converted to the view that the apprenticeship system of training

nurses

is a failure. I have often taken American visitors over my hospital and answered their enquiries. I am always amazed at the apparent hopelessness of our methods as seen by their eyes, and at their despairing admission that after all we turn out in England a nurse who is second to none. As one responsible to some extent for the training of nurses in my own hospital I feel rather like the artist in Don Quixote who, being asked what he was painting, answered modestly: "That is as it may turn out. We do our best according to our lights, and must be judged by the result. And I do not think that everything lies in intensive courses and "quizz" classes.

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I teel that in our hospitals we may to some extent resemble Oxford, as viewed by Professor Stephen Leacock.

"Oxford is a noble University. It has a great past. It is at present the greatest

university in the world; and it is quite possible that it has a great future. Oxford trains. scholars of the real type better than any other place in the world. Its methods are antiquated. It despises science. Its lectures are rotten. It has professors who never teach and students who never learn. who never learn. It has no order, no arrangement, no system. Its curriculum is unintelligible. It has no president. It has no state legislature to tell it how to teach, and yet it gets there. Whether we like it or not, Oxford gives something to its students, a life and mode of thought which in America as yet we can emulate but not equal.

We in England are conservative, bound to some extent by tradition, influenced by atmosphere and antiquity. self-depreciatory and yet hard to move.

Are we right or are we wrong in our methods? I feel that the result, and not the theoretical curriculum, is the criterion by which we should be judged.

PROBATIONERS' ACCOMMODATION AND

SOCIAL LIFE

There is no space in this short review to dilate upon the report of the Rockefeller Committee on this aspect of a nurse's training. One statement impressed me very much : "No Training School of the group studied has as yet provided single rooms for all its students". Privacy for a probationer is quite as desirable as 45 hours' instruction in Bacteriology.

It appears very doubtful if the recommendations of the Committee either as regards the shortening and intensifying of the curriculum or the provision of a lower grade of nurse will meet with the approval of the Medical and Nursing Profession in the United States. It is almost certain that they will not be approved in England. Nevertheless the report of the Rockefeller Committee is such an important piece of investigation and such a stimulating document that, as has been said above, it should be read by everyone who is interested in the training of nurses in any country.

Industrial Welfare Workers

by

Dr. René SAND

(1)

sider this was the beginning of the industrial welfare secretary.

The work of the Red Cross has always been this work would secure the services of an outso closely allied with that of social welfare agencies that it is hardly necessary to call attention to the importance of organizations for the promotion of the health and wellbeing of the working-classes.

Although the activity of the Red Cross as a general rule does not extend to the factories themselves, industry is a vast field for Red Cross propaganda, health education, First Aid and life-saving, public health nursing, and for the facilities afforded by the playgrounds, health centres, dispensaries and clinics organized by the Red Cross.

In order to secure the best results from this work, the Red Cross can either appeal to workmen's associations, particularly benefit societies, or else co-operate in the welfare work organized by manufacturers. Of course, the employment of one of these two methods does not necessarily mean the exclusion of the other. We have already studied the first (2), let us now consider the second.

The first social work in industry was carried on by the employers, and more than a century ago, in the foundries and steel works of Sweden, we find the first social welfare secretary. These foundries were family industries and were usually remote from the large centres; the employer would, therefore, look after his staff in a fatherly fashion, and his wife and daughters would devote a large part of their time to the women and girls and the sick. It naturally happened quite frequently that the employer who had no family of his own to help him in

(1) Lecture delivered to the Association des ingénieurs et des industriels belges, under the chairmanship of M. Moyersen, Minister of Industry and

Labour.

(2) Health and the Workers, Dr. René Sand (International Labour Review, April 1923, VII, 4, pp. 543-550),

Organizations for the welfare of industrial workers began about the same time. Dale in 1792, and Robert Owen about 1830, constructed model factories. Arrowsmith, another English manufacturer, who provided gardens and libraries for his workmen, wrote in 1848 that this equipment increased the working capacity and good-will of his staff and amply repaid him for the money he spent.

Within the last twenty years, Lord Leverhulme, who created the garden city of Port Sunlight, the Cadbury brothers, who founded the model city of Bourneville, and Mr. Seebohm B. Rowntree, an industrial welfare theorist who put his theories into practice, have shown, by improving the living conditions of their employees, that the well-being of the workman contributes to industrial prosperity. Similar experiments have been carried out in France, notably in Mulhouse, in Germany, and other European countries.

In America, industrial welfare work dates. from Pullman, who built the first garden city, near Chicago, in 1880. In 1892 the National Cash Register Company, observing an alarming decline in the quality of their products and attributing it to the unwholesome conditions in which their employees lived, also provided gardens, canteens, schools and playing fields for their workmen, and the almost immediate improvement in their production was beyond all expectations. About the same time the Filene brothers, proprietors of a large department store in Boston, and the. Curtis Publishing Company in Philadelphia introduced similar reforms.

But the most noteworthy experiment was that of Birmingham (Alabama). Coal-mining

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