SOCIAL SCIENCE ASSOCIATION 
OF 
PHILADELPHIA. 
TRAINING OF NURSES FOR THE SICK. 
READ BEFORE (JANUARY 20, 1876. 
DR. JOHN H. PACKARD. 
REPRINTED FROM THE PENN MONTHLY FOR MARCH, 1876. 
720 LOCUST STREET, PHILADELPHIA, PA. THE FOLLOWING IS A LIST OF THE PAPERS READ BEFORE THE 
ASSOCIATION. 
1871. Compulsory Education. By Lorin Blodget. 
Arbitration as a Remedy for Strikes. By Eckley B. Coxe. 
The Revised Statutes of Pennsylvania. By R. C. McMurtrie. 
Local Taxation. By Thomas Cochran. 
Infant Mortality. By Dr. J. S. Parry. 
1872. Statute Law and Common Lazo, and the Proposed Revision in Penn- 
sylvania. By E. Spencer Miller. 
Apprenticeship. By James S. Whitney. 
The Proposed Amendments to the Constitution of Pennsylvania. By 
Francis Jordan. 
Vaccination. By Dr J. S. Parry. 
The Census. By Lorin Blodget. 
1873. The Tax System of Pennsylvania. By Cyrus Elder. 
7/z< Work of the Constitutional Convention. By A. Sydney Biddle. 
What shall Philadelphia do with its Paupers ? By Dr. Ray. 
oportional Representation. By S. Dana Horton. 
Statistics Relating to the Births, Deaths, Marriages, etc., in Philadelphia. 
By John Stockton-Hough, M. D. 
On the Value of Original Scientific Research. By Dr. Ruschenberger. 
On the Relative Influence of City and Country Life, on Morality, Health, 
Fecundity, Longevity and Mortality. By John Stockton-Hough, M. D. 
1S74. The Public School System of Philadelphia. By James S. Whitney. 
The Utility of Government Geological Surveys. By Prof. J. P. Lesley. 
The Law of Partnership. By J. G. Rosengarten. 
Methods of Valuation of Real Estate for Taxation. By Thomas Cochran. 
The Merits of Cremation. By Persifor Frazer, Jr. 
Outlines of Penology. By Joseph R. Chandler. 
1875. Brain Disease, and Modern Living. By Dr. Isaac Ray. 
Hygiene of the Eye, Considered with Reference to the Children in our 
Schools. By Dr. F. D. Castle. 
T e Relative Morals of City and Country. By Wm. S. Peirce. 
Silk Culture and Home Industry. By Dr. Sami. Chamberlaine. 
Mind Reading, etc. By Persifor Frazer, Jr. 
Legal Status of Married Women in Pennsylvania. By N. D. Miller. 
The Revised Statutes of the United States. By Lorin Blodget. 
1876. Training of Nurses for the Sick. By Dr. John H. Packard. ON THE TRAINING OF NURSES FOR THE SICK.1 
MISS NIGHTINGALE, in opening the preface to her " Notes 
on Hospitals," says : "It may seem a strange principle to 
enunciate, as the very first requirement in a hospital, that it should 
do the sick no harm." But she goes on to show that hospitals may 
be so defective in contrivance and management that their inmates 
are in many respects placed at a disadvantage in their struggle with 
disease, or even exposed to new sources of danger; thus being, as it 
were, betrayed by their own allies. 
When, however, we consider the word "nursing," and all that it 
implies-the host of kindly images it calls to mind-it may seem 
even more strange to say of this service that its first requisite is that 
it should do its recipient no harm. And those of us who have had 
the good fortune to find the evils of sickness mitigated by the tender 
care of skillful nurses, whether bound to them by ties of friendship 
or kindred, 'or serving for wages, may be inclined to doubt the 
necessity of any further provision in this matter. Let me say here, 
that in the majority of cases of severe illness, the battle is fought 
mainly by the nurse. The ablest medical advice may be of no avail, 
even if carried out, unless gentleness, firmness, care in many details 
to be hereafter mentioned, tact and common sense, are possessed by 
the constant attendants of the sufferers. Men there are, as well as 
women and children, who have such tenacity of constitution as to 
conquer even desperate disease, in spite of neglect and even bad 
treatment; but these are rare exceptions. In the main, the issues 
are determined in a great measure by faithful and skilful nursing, or 
the want of it. 
Probably few persons have ever asked themselves the question- 
" How are the sick nursed?" The general answer would be-"Oh, 
by their families, or their servants, or their friends." Fortunately, 
in many families there are servants who in cases of sickness assume 
the role of nurses as a matter of course. Their long-tried faithful- 
ness, the reciprocation of kindly feelings and good offices, and the 
1 By John H. Packard, M. D., one of the Surgeons to the Episcopal Hospital, 
Philadelphia, 4 
Training of Nurses for the Sick. 
experience they have gained on like occasions, combine to make 
their services in this capacity both acceptable and efficient. Often, 
again, the members of a family will take this duty upon themselves, 
and become by the force of affection skilled in the work. Or a 
friend will give up all other engagements for such a labor of love, 
and fulfil the task well. 
But there occur many cases in which these resources are wanting, 
or are exhausted by the demands on them, as in severe and long- 
continued illness, or when several members of a household are 
stricken down at once. How are these to be supplied? 
Under such circumstances, the physician, or some friend or ac- 
quaintance, is called upon to recommend a nurse. It may be that 
the choice made in the emergency happens to be a good one; a 
person of skill and experience is obtained, and all goes well. But it 
may be that experiment after experiment is tried; a succession of 
ignorant, noisy, conceited, careless, or even dishonest or intem- 
perate characters come and go, the poor sufferer perhaps losing his 
life before any one worthy the name of a nurse appears upon the scene. 
This picture is not too strongly drawn. Let me quote from a 
high authority in England, where for a number of years organized 
and earnest efforts have been made to establish a better order of 
things. The London Lancet, speaking of a report from the sub- 
committee of the National Nursing Association, says : 
" This report shows in detail, and most truthfully, how many lives 
in all grades of society are annually sacrificed, because persons can- 
not be found to carry out skilfully.and faithfully, as well as tenderly, 
the advice and directions of the physician. This want affects rich 
and poor alike. Many of those who live in palatial establishments, 
and are able to obtain anything and everything that money will buy, 
have experienced the sad fact that the lives of those nearest and dear- 
est to them have been lost, because the careful conduct of the 
nursing was not properly provided for. And the same want exists 
in the homes of the poor." 
So urgently was this need felt in the city about forty years ago, that 
a nurse society was organized, which is still in active operation; but 
it is identified with a Lying-in Charity to such a degree as to make 
the furnishing of nurses, for other than cases of confinement, of 
necessity a subordinate feature. One or two extracts from its last 
report will, however, afford some additional evidence upon our 
present subject. The managers say, quoting from the Report for 
1853, published in 1854: Training of Nurses for the Sick. 
5 
"It is still true that 'The want of efficient nurses, not only in 
obstetrical cases, but in sickness generally, is widely felt in our com- 
munity, and we have constantly been made acquainted with the 
great difficulty experienced in procuring good nurses, even by those 
who have the means to pay liberally for their services. The rapid 
increase of our city makes this want annually greater, and calls for 
a systematic arrangement by which this most useful occupation, so 
peculiarly within the sphere of women, shall be opened to such as 
are naturally adapted to its duties and responsibilities. To train 
such in the necessary acquirements, and introduce them favorably 
to notice when deserving, and to supply the demand for nurses, by 
establishing a communication between them -and the public, is one 
object of our society.' " 
They say further, speaking of the preceding ten years' work: 
"More than six thousand citizens have applied at the institution 
for nurses, of whom about four thousand have been supplied. The 
excess of applications for nurses beyond our capacity to supply them, 
has been a constant and unvarying feature since the founding of 
the nurse school, verifying the quotation given above from the Report 
for 1853." 
It would be but wasting time to argue at greater length as to the 
need of additional provision for the efficient nursing of the sick in 
all classes of the community. Let us proceed to consider what we 
want, and how to get it. 
The remarks now to be made will have reference especially to the 
training of female nurses; for the reason that among women we 
find the best material for the discharge of these duties, and that it 
would be impossible, except in military organizations, to find such 
a demand for male nurses as would warrant the establishment of 
training schools for them. It is indeed extremely seldom that cases 
occur in civil life, requiring attendance which cannot be given by 
women; and when a male nurse has been needful, so far as my ex- 
perience or observation has gone, there has never been any difficulty 
in obtaining one. 
Permit me here to quote from Dr. O. W. Holmes a passage, the 
aptness of which will, I trust, be apparent, and which may recall to 
some of us characters that we have had the good fortune to know in 
real life: 
"She had that genius of ministration which is the special province 
of certain women, marked even among their helpful sisters by a 
soft, low voice, a quiet foot-fall, a light hand, a cheering smile, and 
a ready self-surrender to the objects of their care, which such trifles 6 
Training of Nurses for the Sick. 
as their own food, sleep, or habits of any kind never presume to in- 
terfere with." 
As far as natural qualifications go, such a woman would make a 
perfect nurse; but there are many details which even she would be 
apt to overlook, unless she had had the benefit of instruction. Train- 
ing is as needful for a nurse, as for a physician, a book-keeper, or 
any other skilled laborer. 
Our sources of supply of nurses, so called, may be summed up as 
follows: Sisters of Charity, who, as I have been informed by one 
of their Superiors, a woman herself of large opportunities for knowl- 
edge, have no systematic instruction, but pick up what they can by 
serving in hospitals; other women who, having been employed as 
nurses in hospitals, have likewise acquired more or less experience 
in their duties; women who have taken up nursing in default of 
other occupation; and monthly nurses who have either temporarily 
or permanently taken to a more general line of business. 
Many of these nurses do their work fairly well; but there is no 
standard of qualification. I have known one woman who had abun- 
dant employment in this city, and was considered an admirable 
nurse, who could not read. This fact of itself would condemn our 
present system, or rather want of system. 
It may be well now to state what are the qualifications which 
ought to be possessed by a trustworthy nurse, and to lay down some 
general principles as to her duties, before offering any suggestions 
as to the mode of training. 
Honesty and sobriety, and readiness to obey the orders of the 
physician, may be taken as matters of course; without these, no 
woman can be fit to take care of the sick. Sound health, and aver- 
age strength, are equally indispensable. Another essential quality 
is a thorough interest in the work-that self-surrender which Dr. 
Holmes speaks of in the passage before quoted, and which is further 
set forth by Miss Nightingale, as follows : 
"I have seen sisters down upon their knees scouring a room or 
hut, because they thought it otherwise not fit for their patients to go 
into. They had the true nurse-calling-the good of their sick first, 
and second only the consideration what it was their "place" to do 
-and women who wait for the housemaid to do this, or for the 
charwoman to do that, when their patients are suffering, have not 
the making of a nurse in them." 
The habit of thorough cleanliness of person, and of neatness and Training of Nurses for the Sick. 
7 
simplicity of attire, need hardly be insisted upon. The dress should 
never be of such a texture and color as "not to show dirt." No- 
thing can be worse than draperies which rustle, or which catch in 
things and knock them down. 
Quiet and self-possessed manners and a low voice are of no 
small importance in "the sick room. They are entirely consistent 
with the firmness and collected demeanor which will soothe and 
control a weak and perhaps wayward patient. Circumstances 
sometimes occur-unexpected or alarming symptoms-which de- 
mand both courage and calmness in the attendant; and as a pre- 
paration for meeting these, the habit of self-possession is invalu- 
able. Adults as well as children, in sickness, often feel the need 
of being gently controlled; and to do this requires not the assump- 
tion of authority, but calm firmness, and the exercise of ready tact. 
Loud talking, or that far more aggravating undertone which just 
prevents the invalid from hearing what is said-discussion of any kind 
.-all these areapt to do much harm in the sick-room. The rattling 
of newspapers, humming of tunes, or the making of any needless 
noise, will grate upon an ear rendered sensitive by weakness. 
A nurse should never invite her own friends to come into the 
sick-room, nor should she allow visitors to the patient, if such are 
admitted by the physician's orders, to stay too long, or to introduce 
topics which can be exciting, whether agreeably or otherwise. 
Nurses need training in regard to the care of the sick-room. 
Everything should be kept cleanly and in order. This can only be 
done by constant care. Eternal vigilance is the price of a good 
many things besides liberty. Medicines, glasses, napkins, every- 
thing should be arranged so as to be easily found at a moment's no- 
tice. Dusting should be done very quietly, and without fuss or 
annoyance. All slops should be emptied at once. The ventilation 
of the room should be carefully attended to, under the physician's 
direction, if necessary. The temperature of the room should invari- 
ably be regulated by medical order, and tested by the thermometer. 
All the food and medicine should be given with order and method, 
at prescribed times; in many cases a written schedule should be 
followed. In regard to these matters, or the changing of sheets, etc., 
there should be no talk beforehand. To a sick person, the mere 
knowledge that something is to be done is burdensome. Every- 
thing should be quietly prepared, and then the nurse should act, 
steadily, gently, and without fuss or bustling about. 8 
Training of Nurses for the Sick. 
As to her relations with the physician, the nurse ought always to 
take his directions with the utmost care and attention. At each 
visit, she should make to him a clear and faithful report of what 
has occurred, from memoranda if necessary. For instance, should 
the patient have had a chill, the nurse should be able to say 
when it took place, how long it lasted, what was the degree 
of fever following it, and whether or not there was subsequent 
perspiration. Few nurses can be trusted to make reports of 
the pulse, and fewer still to observe the temperature of patients. 
These are matters which require professional knowledge, and habits 
of observation not to be looked for in any but specially-educated 
persons. It may be, however, that when other points of training 
are thoroughly acquired, these may be added in exceptional cases. 
It would be impossible, within our present limits, to speak of all 
the duties of a nurse about the sick, in anything like detail. These 
duties will doubtless suggest themselves. 
One word may not be out of place as to a matter in which un- 
trained nurses are apt to err. No prognostications should ever be 
indulged in, whether gloomy or otherwise, or reported as coming 
from the physician, either to the patient or the friends. No narra- 
tives of other cases should be offered; and indeed the nurse should 
remember that her business is not to talk, but to act. 
We are now prepared to consider what measures may be advisable 
towards the establishment of a system by which a supply of well- 
trained nurses may be secured for the community. And in the first 
place, we must look to the large hospitals as the great schools for 
nurses, as they undoubtedly are for physicians. Other things being 
equal, the more perfect the organization and regulations of these 
institutions, and the more complete their sanitary arrangements, the 
better qualified will be the nurses trained in them. With the co- 
operation of the medical staffs of these charities, an influence may 
be exerted which will be felt far beyond any calculable limits. The 
writer in the London Lancet, before quoted, says further : 
" A training school is proposed in close connection with a hospital, 
a district home in the vicinity of the hospital, and responsible to the 
training-school, which home shall, so to speak, nurse the district 
immediately surrounding it, and also send out nurses to other dis- 
tricts. A year's hospital training, and three months' work in the 
' head-quarters' district home are to qualify for the certificate of 
competency." Training of Nurses for the Sick. 
9 
Institutions of this kind have already been in. operation, more or 
less successfully, on the continent of Europe, at Carlsruhe, Darm- 
stadt, Kaiserswerth, Dresden, and Berlin; in London, at the King's 
College and St. Thomas's Hospitals; and in Dublin, at Sir Patrick 
Dun's Hospital. There is also a training-school at Liverpool, for 
which a hospital has been built. The first two of these are parti- 
cularly praised by Miss Lees, in her " Hand Book for Hospital Sis- 
ters." The French hospitals are made of use in the training of male 
nurses, the Sisters of Charity being employed more as assistant- 
matrons. 
In this country, the only training-schools of which I have any 
knowledge are five-two in New York, one in Boston, one in New 
Haven, Conn., and one in this city. Of those in Boston and New 
Haven, I have no information except that there are such institutions. 
One of those in New York is connected with the Bellevue Hospital, 
and has been in active operation for nearly two years; it is rapidly 
gaining the confidence of the public, and its value is fully recognized 
by the physicians. A medical friend writes me, that there is "no 
lack of good material for nurses, and the applicants for admission 
are from the middle and better classes of women." He says also 
that "apart from hospital nursing, the graduates find an ample 
field as private nurses, and the demand for them exceeds the sup- 
ply." 
The other New York school is attached to the Charity Hospital 
on Blackwell's Island, and has only been in existence for a few 
months. The one in this city is connected with the Woman's Hos- 
pital, and is conducted on a well-arranged system; but the training 
cannot be, in a special institution like that, sufficient to meet all the 
needs of a large population. Good as it maybe as far as it goes, its 
recipients have still much to acquire before they can enter as experts 
upon general nursing. 
It would perhaps be interesting, did time and space permit, to 
give a sketch of one or more of the leading institutions for nurse- 
training, and to see how they show the impress of the social condi- 
tions surrounding each. But the general plan followed has varied 
very little, and indeed there is not much room for variety in es- 
sentials. 
I cannot but remark, however, that it seems to me that in some 
of these schools the error has been committed of carrying the train- 10 
Training of Nurses for the Sick. 
ing so high as to develop a nondescript official-not a doctor, but 
more than a nurse; unequal to great emergencies, and yet too 
learned to be humble and assiduous in the drudgery inevitable in the 
sick-room. Thus at St. Thomas's Hospital, Miss Lees tells us, the 
pupil-nurses are taught to dress wounds, to take accounts of cases, 
to make and apply bandages; are required to hear lectures on anat- 
omy, physiology, pathology, and the chemistry of common life. 
One could hardly expect the resulting cyclopedia to submit to direc- 
tions, unless from some one who had a certificate that he knew more 
than she did. 
In concluding this paper, I beg to offer a brief sketch of a plan 
for an organization to take charge of women desiring to become 
trained nurses, to aid them in their object, and to afford the medi- 
cal profession and the public facilities for obtaining their services. 
To effect a beginning, it would be needful to start a subscription, 
and to have a sum of at least ten thousand dollars pledged to the 
support of the enterprise. The contributors should then hold a 
meeting, and proceed to the election of a board of lady-managers, 
with the usual officers-president, vice-president, secretary and 
treasurer. A board of counsel, consisting of four or five gentlemen, 
might be appointed to give their advice and assistance when desired. 
To a committee of these ladies application might be made by any 
women desiring to obtain instruction in nursing under the auspices 
of the society. Such women should be required to give evidence of 
good character, and to be free from present ties which would hinder 
their faithful use of the opportunities they sought. They should be 
healthy, of suitable age, and with a certain amount of practical edu- 
cation. A small fee might be required, and a pledge to remain under 
instruction, unless dismissed for reason, for a period of three or six 
months, or a year, at least. 
By arrangement entered into with some large general hospital, 
these candidates might then be entered as probationers, and em- 
ployed in actual work at the bedside. In such an institution it 
would be needful to have these probationers under the control of a 
head, perhaps the regular matron, who should see that they observed 
stated hours, that their work was properly done, and that their time 
was profitably spent. The wards, if large, and giving employment 
to several probationers each, might have a "sister" to take the imme- 
diate oversight of the pupils. Training of Nurses for the Sick. 
11 
During all their period of probation, monthly or more frequent 
reports might be made to the committee of the society, by the over- 
seers, as to the conduct and capacity of its protegees; and any spe- 
cial matter, such as misconduct, carelessness, or gross stupidity, 
necessitating dismissal, should be at once made known to them. 
Such probationers as passed successfully through the trial of a cer- 
tain period-a year, for instance-might then be admitted to the 
higher grade of pupil-nurses. These should be entrusted, under the 
oversight of an advanced pupil, or a "sister," with the special care 
of one or more grave cases, either medical or surgical. Each should 
have charge in turn, for a month, of the bedding and other ward 
supplies; and the same arrangement might be made as to the cook- 
ing, for cases requiring food not supplied on the regular diet-table 
of the ward. 
Lectures of a thoroughly practical character, having reference 
strictly to matters belonging to the nurse's province, might be 
delivered to the pupils by members of the hospital staff. 
During the second year of tuition, pupils whose services were not 
required in the hospital might be allowed to engage in attendance 
upon cases of severe illness at the homes of the patients, either in 
connection with a dispensary or in the private practice of physicians 
in good standing. 
At the end of a two years' term of training, each nurse might, 
either upon certificate of the sister in charge and the hospital staff, 
or after examination, receive from the society a diploma; and this 
would soon become a recognized guarantee of capacity and trust- 
worthiness. 
One incidental advantage which would result from this, seems to 
me so great as to deserve special mention. I refer to the influence 
for good which would inevitably be exerted upon the subjects of 
this skilled attendance; the purifying and refining of squalid homes; 
the benefit of contact with persons whose very office would demand 
a certain moral tone, the more powerful because not directly aimed 
at the correctipn of vice, and the more effective because encoun- 
tered under the softening and subduing circumstances of sickness 
and trouble. No one can estimate the extent to which a force of this 
kind might continue to work, long after the immediate occasion for 
it had passed away. 
During the time of this training, the pupils would be under the 12 
Training of Nurses for the Sick. 
supervision of the society, but would for the most part have their 
board and lodging at the hospital in which they might be on duty. 
For unattached pupils, and for graduates who might desire it, a 
home should be provided, where, for a reasonable charge, they 
might live, and where a register should be kept, to enable physicians 
and the public to obtain the services of a competent nurse whenever 
occasion should arise. 
Notable instances of good conduct on the part either of pupils or 
of graduates-such as courage in time of an epidemic, or a long 
period of devotion to trying duty, or a good record of ten years' 
consecutive service in nursing-might be recognized by the society, 
and testimonials awarded in the shape of certificates or medals. 
Such is a brief and very general sketch of a plan, in the main the 
same as those elsewhere adopted, by which a great and acknowl- 
edged want might be met, and under all ordinary circumstances a 
supply of qualified nurses be ensured to the sick in every class of 
the community. One practical point, upon which the whole of this 
system of training hinges, must not be overlooked. How would 
such a scheme be regarded by those in control of our hospitals? 
That they would meet it with favor, we cannot doubt. The diffi- 
culty of obtaining good and reliable nurses, at present continually 
felt, would be permanently solved. Far more efficient service would 
be commanded, at a smaller expense. A fresh claim would be 
established upon the public, who would sooner or later recognize 
and respond to it. These reasons alone would secure the counte- 
nance of hospital authorities to a system of nurse-training, instituted 
under proper auspices. There can be no reasonable doubt that in 
a city like Philadelphia, where the claims of mere charity are so 
promptly met and so generously responded to, the means of support 
for an institution like that now described would be abundantly forth- 
coming. The expenses of the New York training school are 
estimated in their report at about $12,000 a year. A much larger 
sum would be well invested in securing the great benefits, direct and 
indirect, which would be derived from the efficient carrying out 
of the ideas which it has been the object of this paper to set forth. 
I wish that a much larger space, and a far abler pen, subject to 
fewer interruptions, could have been employed to bring this matter 
forward; but it may be hoped that the merits of the cause will make 
amends for any defects in its presentment.