WY \M9l9ri 18S8 A NEW WAY of TRAINING NURSES gfer acaaou ^ qjC :x :: j co ^ -^ ^ ^^a»g-p | Surgeon General's Office HM^Mi A 0 4NHEI C/" tf; ft. P. hf*tcJt, (f) PRESENTED BY| A NEW WAY OF TRAINING NURSES. o4l A NEW WAY TRAINING NURSES BY A. WORCESTER, A. M., M. D. FELLOW OF THE MASSACHUSETTS MEDICAL SOCIETY PHYSICIAN TO THE WALTHAM HOSPITAL BOSTON CUPPLES AND HURD 94 Boylston St. 1888 I??? Copyright, 1888, By CUPPLES AND HURD. A 11 rights reserved. PREFACE. Since the first publication of the sec- ond paper of this series, many questions have been addressed to the author by those who are desirous of establishing Training Schools. The reprints of that paper having been exhausted, it has been more than ever impossible by letter writ- ing to supply the sought for information. In deciding to republish the paper, it has seemed well to publish with it a more complete history of the Waltham Train- ing School than was originally given, and also a paper upon the same subject, but more in direct reply to the questions that have been asked. A. W. Waltham, May i, 1888. CONTENTS. HOW TO START A NURSES' TRAINING School ......... n The Training of Nurses in Pri- vate Practice...... 57 The Waltham Training School for Nurses.......87 HOW TO START A NURSES' TRAINING SCHOOL. HOW TO START A NURSES' TRAINING SCHOOL. In every community, and es- pecially in small towns, no little difficulty attends the inaugura- tion of any enterprise. No ex- ception to this rule will be made in favor of a scheme to train nurses. The conservatives will try to throw cold water upon it, by asking in great alarm what would become of Widow Smith and Spinster Green, who as it is, can barely earn their bread, now 12 A New Way of that the city nurses are employed in so many of the wealthiest families. And with the next breath they will ask, who in town would be willing to employ young ignorant nurses. There is no denying that an innovation is contemplated. The public has learned to respect physicians who do not profess to know everything, but not to re- spect the same trait in nurses. The old style nurse was not an unmixed blessing, and one of her most serious faults was that she never would confess to ignorance of anything. She had always " seen a worse case," and to prove it she was too ready to rehearse all its horrors. But she was a Training Nurses. ij great worker. Up at daylight, after no matter how broken a night, she would have the pa- tient's washing out on the line before breakfast; by dinner time it would all be ironed, and by sup- per time half the family mending would be done. Any offer of a substitute watcher by day or night would be scornfully refused, although the patient at midnight might have to be fairly strong in lung power to wake up the good old nurse. Not until after one full generation has outlived the last of the old style nurses will their type be forgotten. Until then, the modern nurse who openly admits that she is a learner, who finds full enough work in the sick-room i4 A New Way of without going into the laundry, and who, even so, needs a part of every twenty-four hours for rest, will have to win her way in spite of the prevalent notions of what nurses are and what they can ac- complish. None of these objections to the reform need discourage its incep- tion. Widow Smith and Spinster Green, if they are honest, will be among the first to praise the new order of things. They will wish out loud that they could have had such training as the new nurses have; they may even apply for places in the school. And the families who employ the student- nurses will surely discover and proclaim the advantages of hav- Training Nurses. 15 ing nurses who know what they do know, and are quick to ask where they do not know, how to do this and that, who can keep accurate bedside records, who can follow the physician's orders implicitly and report to him in- telligently ; nurses, in short, who aspire to be perfect and know that they yet have much to learn. One of the great benefits of the new regime is the better separa- tion of the very different works of the nurse and the physician. The latter, it is true, ought to under- stand the nursing service in all its details, but the nurse need not understand and must not assume the medical or surgical responsi- bilities, and she, therefore, is free 16 A New Way of to acquire and to practise the art of nursing to a far greater profi- - ciency than the busy practitioners of medicine can attain. But, in spite of the fact that the more a nurse is taught the less likely she is to assume medical responsibili- ties, a popular prejudice exists against trained nurses on the ground that very likely they know too much. These and all other possible objections to trained nurses must be well considered by those who would undertake the establish- ment of a training school. The experience of those who else- where have* made the undertak- ing should be thoroughly studied to see if the objections that will Training Nurses. iy be raised are well or ill founded. And then by talking the matter over with all who possibly may be interested in the scheme, it will be possible to estimate its feasibility. The question of the part the physicians will take is a vexing one. Unfortunately, it is hard to make doctors pull together. There is little fear that they will not use the student-nurses and be thankful for them after they are trained, but there need be equally little hope of their all taking hold of the work, at least at the start. The younger doctors can do most because they., have more leisure and are more ready to take up new things, and espec- 18 A New Way of ially because they are more likely to have seen the advantages of the new order of nurses. The clergy will take deep in- terest in the success of the move- ment. The care of the sick was formerly within their province, and, now-a-days, either as a precious inheritance of the Church's pristine unity, or as an equally precious omen of a still deeper union yet to come, in mat- ters pertaining to the relief of physical suffering, clergymen seem glad to pull together. In order surely to enlist all who will help by giving time or money to the cause, a public meeting should be called, cordially invit- ing the presence of all inter- Training Nurses. ig nested in the subject. At this meeting let the scheme be fully discussed. But it must be ar- ranged beforehand what is to be said and who is to speak, or else nobody will find out what it all means. Some one must be there ready to tell what has been else- where accomplished; another to tell what the advantages of trained nurses are to patients and their physicians, and the induce- ments that the new profession offers to women entering it. Thus all objections may be fore- stalled. The clergymen and the physicians can be called upon to set forth these subjects; but, after all, the real work of establishing and of carrying on a nurses' train- 20 A New Way of ing school will inevitably fall up- on women's shoulders. Men can help in various ways, and the co- operation of the physicians is ab- solutely essential, but the details of management must be attended to by women. After the advantages of having a training school have been dis- cussed, if then there appears an enthusiasm born of conviction, it will be well at this first meeting to proceed at once to the appoint- ment of a committee of women to whom shall be entrusted the whole management. This com- mittee will naturally include the original movers in the matter if they are willing to serve. Three makes a good number for such a Training Nurses. 21 committee, and they may as well be called-managers from the first, for the whole responsibility of the undertaking will fall upon them. For this very reason it is well that they should be appointed at a public meeting, for they certainly will be working for the public good and the success of their ef- forts will ever depend upon their having hearty public support. Of this committee, one ought to have considerable business ability. Much depends upon the Treasurer in every such under- taking. At the start, however small the venture, there will be some expense which can be met only by raising a subscription. And for the first year, at least, 22 A New Way of a guaranty fund is essential, from? which may be drawn enough to cover any possible deficit. After the first year the school ought to be self-supporting, but even then a guaranty fund and a reasonable bank balance in the Treasurer's. favor, ought to be maintained to insure her against all unneces- sary worry. The necessity is therefore very plain of selecting for this office some one who is well known in the community, who is a sure account- ant and able to present the finan- cial status in such way that it can be readily understood, one who- will heartily strive to interest in the enterprise all who are able to give of their means either di- Training Nurses. 23 rectly or by subscribing to the guaranty fund. In deciding upon what shall be taught in the training school it is to be borne in mind that there is a distinct division be- tween strictly medical training and domestic training. The for- mer should be left entirely to the physicians to decide upon its scope and character: the latter should be likewise entrusted to the lady managers. But the gen- eral purposes and methods ought to be discussed and decided at joint meetings of the managers and of the physicians who take active part in the enterprise. These meetings are to be called at the request of either party. 24 A New Way of As in many other matters it is not of so much consequence how the questions are decided as it is that these shall be decided unani- mously by all who are responsible for the success of the school. There can be little difference of opinion about the duration of the proposed course of training. Two years is the time usually adopted. The first year can then be employed more especially in teaching the student-nurses. Dur- ing the second year, in accord- ance with the general law govern- ing apprentices, the nurses, while gaining more experience and in wider fields of usefulness, can be earning more money for the school. Training Nurses. 25 The number of physicians serv- ing as instructors in the school will largely determine how often the student-nurses shall assemble for their lessons. No one physi- cian will probably care to meet the class oftener than once a week, although at his office he will occa- sionally be glad of a nurse's assist- ance and eventually he will often want to take a nurse out to cases for her help during or after his visit. Much valuable instruction will be given to the nurses in this way. Besides the regular lessons given at the class-room by the physicians, lessons in cooking, in the housework of the sick-room, also in massage, if the services of a teacher can possibly be 26 A New Way of secured, must be arranged for and may well be given at the regular afternoon lesson hour. These frequent meetings of the nurses do much to establish that esprit de corps which is essential to their best success. And the disadvan- tage to their patients of having the nurses go out for an hour or two every afternoon is not so great as at first thought it would appear to be. If the patient is very ill, the nurse will of course stay at the bedside; but when the patient is comfortable, and when others stand ready to take the nurse's place, it is beneficial to both patient and nurse for the latter to go out for the refreshment of mind and body that the lesson Training Nurses. 2J and the walks to and from it will give her. And no matter how sick the patient, nor how satisfac- tory the nurse, it is still a great advantage to both for the nurse to be well out of the sick room for a part of the twenty-four hours. This necessity of going to her lessons limits the distance from the class-room of cases to which the student-nurses during their first year may be assigned. The fact, too, that their training mainly depends upon the instruc- tion they receive from the physi- cians at the bedside obliges the provision that during their first year they shall be assigned only to the patients of those physicians 28 A New Way of who are instructors in the Train- ing School. This provision is important also as a precaution against the employment of the student-nurses by physicians who would not understand and make allowance for their ignorance. In the second year no such limi- tations are needed: the nurses can then serve under any physi- cian and anywhere; only, for a month or so before they are gradu- ated from the school, they should be again assembled for final re- views of what they have been taught. The experience they will thus gain by serving under different physicians will fit them for their life work. In this re- spect and in the fact, too, that Training Nurses. 29 they receive their training in pri- vate families, they have a decided advantage over nurses who are trained only in hospital wards in the service of only a few physi- cians. The only disadvantage is the danger of their not being trained to soldier-like obedience. To guard against this, they must be taught from the first to obey implicitly the physician's orders. And they must be impressed with the supreme importance of perfectly loyal support on the nurse's part. Nursing is an art, and there- fore can be taught only by one proficient in it. A trained nurse is indispensable in founding a training school. Fortunately, it jo A New Way of is easy to procure such service. For many go through the train- ing schools, not merely to fit themselves to be excellent nurses, but to be able also to teach the art to others, and so to spread more widely its benefi- cence. By applying to the train- ing schools to recommend one of their graduates fitted for such a position, a head nurse can be secured at much less salary by the year than her usual wages would amount to. And a large part of her salary can be earned by her service in families where most proficient service is requir- ed, and where there is a willing- ness to pay well for it. This kind of service the head nurse Training Nurses. ji can well render while directing the work of the student-nurses. Thus in cases of moderate sick- ness the student-nurses can man- age very well under the direc- tions of the physicians and of the head nurse given at the time of their visits. But in criti- cal cases the head nurse can be put in direct charge, with one or more of the student nurses as assistants. In such cases the school can rightly charge full price for her service. When not so employed, the head nurse can visit the cases where her student-nurses are employed, there teaching them and at the same time giving comfort to the suffering. She will delight in 32 A New Way of such service. It is the kind of work done by the nurses for the " District Visiting" societies, which they greatly like. Much is said nowadays, about the hardships young women suffer who have to earn their own living. Much misdirected effort is made, well meant though it be, to crowd women into lines of work for which they naturally are not so well fitted as men are. Were the same effort employed to develop lines of work in which women, because they are women, can succeed better than men could, there would not be so much jangling about women's wrongs, and the world in every way be better off. Training Nurses. 33 Now, if there is one line of work in which women will always score notable success it is that of nursing. The highest praise of a male nurse is that he has almost feminine tact and delicacy and sympathy. Another proof of woman's peculiar fitness for this work is the effect it has upon her. A purposeless, list- less girl after she joins a train- ing school will bend to the work with noble, womanly enthusiasm, and at once become a new being. Her face brightens, she makes hosts of grateful friends, she has the supreme happiness of know- ing that she is at last of great use in the world. No other occupation, excepting that of 34 A New Way of making a home for her own family, can better bring out all that is best in womanhood. This is now widely recognized. Even in remote villages, splendid girls can now be found who eagerly hope to become trained nurses. It is not always easy for them at once to leave their homes and various employments, nor is it always easy to discover those who would like to join the school. But, as it is best to secure students, so far as is possible, from the immediate neighbor- hood, for every public meeting of the projectors of the school a cordial invitation should be given to all who have any incli- nation to become nurses. And Training Nurses. 33 it must be someone's duty at such meetings to discover these possible candidates, and to talk with them about the subject in all its details. An intelligent opinion may thus be formed by both the candidate and the pro- jectors of the school as to the advisability of the former's be- coming a student-nurse. After every effort has been made, it may be impossible to assemble from the neighborhood the three, or five, or ten young women who are wanted for the first class. Such failure, how- ever, must not persuade the managers to accept candidates who are not in every way satis- factory. A more fatal mistake 36 A New Way of could not be made. Nursing offers to invalids little chance of regaining their health, and to the unlettered almost no chance for acquiring an ordinary school education. Nor is it at all satis- factory to have to say of such a one that she is a good nurse but never well, or of another that she is unable to write decent clinical records. Perfect health is the prime requisite of all who would become trained nurses. Every training school should require a certificate of the appli- cant's physical fitness for the work, either from the regular medical attendant or from some physician employed for the special purpose. Training Nurses. 37 The age of the applicants is a question to be carefully con- sidered before deciding upon the limits to be observed in accept- • ing them. It is a great mistake for women past the prime of life to undertake nursing, and espec- ially so to undertake a course of several years training in the art. It is a still greater mistake for girls, before reaching full matu- rity, to engage in work that not seldom demands the fullest powers of endurance. The usual limits of age, twenty-five and thirty-five, are safe enough; but in the smaller schools, where consistency is not so necessary, it may often be found advisable to make exceptions to these limits. 38 A New Way of The age and the physical fit- ness being satisfactory, the ques- tions then come concerning the applicant's character and the amount of education they pos- sess. Certificates of excellent character, given by entirely responsible parties, are indispen- sable. Fortunately it is itself no slight evidence of good character to have applied for service in a training school. But the respon- sibilities upon the managers are so weighty that the fullest in- quiry concerning applicants can be none too searching. In the matter of the amount of preliminary education neces- sary, while there is no such thing as a nurse's having had too much Training Nurses. 3p of that, and the more she has had the better, it is very impor- tant that she shall, at the least, have had a common school edu- cation. Not only that she may be able to write good reports, and to study profitably her text books, and to read aloud accept- ably to her patients, but, what is of still more importance, that her mind may have been trained to good methods of thinking and reasoning about what she hears and reads. After all, the one great desideratum, next to a stock of good health, is that of common sense. When suitable candidates can- not otherwise be found, by apply- ing to the already established 40 A New Way of training schools, it will always be easy to obtain the addresses of young women who have not been accepted as student-nurses in these schools, either for lack of room or for some minor dis- qualifications on the part of the applicants. From these lists there can hardly be any doubt of making up the desired class. For succeeding classes, their friends and their friends' friends can be counted upon. In deciding upon the number of student-nurses to engage for the first class it must not be forgotten that one or more of them may drop out, for one reason or another. There will, of course, be a month of proba- Training Nurses. 41 tion for the sake of both the school and the student-nurse. This will lend some security against the classes dwindling below the desired number; but, as it is not practicable, in a small training school, to take in new student-nurses, except in classes at yearly intervals, in order to provide against even a tem- porary scarcity, the number en- gaged at the start should be somewhat greater than the esti- mate of immediate needs would warrant. Before accepting any candi- dates as student-nurses, the whole financial policy of the undertak- ing must receive full considera- tion. 42 A New Way of The two great questions are what wages to pay to the nurses, and what charges to make for their services. In settling the first question it is to be borne in mind, and made plain to the student-nurses, that the real return for their service is made by teaching them. In other pro- fessions the students have to pay their teachers. But student- nurses are boarded and have, besides, an allowance for their personal expenses, which should include their books and uni- forms. And this, too, whether they are working, or resting, or waiting for cases. The amount of the allowance is generally about $100 for the first year, and about $150 the second year. Training Nurses. 43 The charges to be made by the school for the services of the student-nurses ought to depend upon the prices generally charged in the neighborhood by the old-time nurses. In fairness to them, the charges for the new nurses ought not to be lower, and for the second-year nurses the charges should be somewhat higher than the usual prices. It is not easy to estimate the earn- ings, but it is not difficult to esti- mate the expenses of the school, which must be met by making sufficient charges. Provision must be made to furnish nurses, when possible, to the sick poor, if for no other reason than that this is one of the high purposes 44 A New Way of that will best inspire the public to support the school. This can be done by establishing a special fund for the purpose. Many will readily give for the direct object of supplying a nurse in some given case, who would hesitate about contributing to the gen- eral support of the school. There are two ways of provid- ing homes for student-nurses when not at service. One way is to find separate homes in families where board will be given in return for the assistance of the student-nurses in the household work. This is the ideal way. The other way is to establish the headquarters of the school with some family where Training Nurses. 43 certain rooms are reserved for the nurses' use, and where they can be boarded at some fixed price per meal. This latter way will probably always be found the most practicable, for the usefulness of the nurses depends largely upon their being accessi- ble. Physicians will not see any advantage over the old regime if they have to hunt the town over whenever they want a nurse. Besides, when the nurses are separated, each one must be ready for duty all the time, as it is difficult to arrange for any succession or exchange of this readiness. This is not economi- cal. But the chief difficulty with the separation plan is that few 46 A New Way of families care for such temporary assistance, when there is no tell- ing, either, just when it will begin or end. And the nurses are not so happy as when they have even a corner that they can call their own, and a place to rest on returning from cases where the nursing has been extra hard. Were it not that it is never possible a day in advance to tell whether all or none of the student-nurses will be at home, it would be wise for them, when not at service, to do their own housekeeping. But this neces- sary irregularity, and the occa- sional need of entire rest for the nurses, make this plan also im- Training Nurses. 47 practicable. A boarding-place must be found for them where allowance will be made for their varying number. It will be well, perhaps, to arrange when the number of nurses at home is above a certain limit, that one or more shall be detailed to help the housekeeper, the school being meanwhile relieved of pay- ing for the board of the one so serving. The class-room will be in the house where the nurses live. In it the school's library can be kept. There are already a good many books that nurses ought to read, books that tell of the glorious lives of nurses who have finished their labors, books 48 A New Way of that tell of the training given in the different schools of this country and abroad. And, be- sides these books upon nursing and nurses, there will be needed for the school's library books of reference in the subjects taught by the physicians. Friends of the school may like to give these books, or the money for them. Not much need be done at first. But the need must be kept in mind. When the student-nurses are comfortably established in such way as has just been described, if an extra room or two can be had in the same building, it will be found an easy and natural step to arrange for the care of private Training Nurses. 40 patients there. For beyond the small expense of fitting up the rooms, there is no further ex- pense, except when these rooms are occupied, which will be met by the patients. But this easy out-growth of a hospital, although an exceedingly interesting subject is not strictly within the province of this paper. It will, however, not be amiss to dwell for a mo- ment upon the great advantage it is to a training school to have at least a miniature hospital where the student-nurses can be taught their first lessons under the immediate supervision of the head nurse, and where all the es- sentials of an ideal sick room can be jealously ordered. No matter 30 A New Way of how small this hospital may have to be, it will at least give the stu- dent-nurse something to do and to think about when not out at service. In places where there already exists a hospital of any kind, the training school will naturally be started in connection with it. Hitherto it has not been thought feasible to carry on training schools in the smaller hospitals, and either untrained nursing ser- vice has been put up with, or high wages have been paid to nurses who have been trained elsewhere. Any movement to establish a training school in communities where there are such hospitals will be very wel- Training Nurses. 51 come, and it will doubtless be easy to make arrangements equally advantageous to both parties. One of the dangers peculiar to small training schools is that of belittling the dignity of the train- ing given by not observing such of the customs of the larger schools as are founded upon im- portant principles. In the mat- ter of uniforms, for instance, the student-nurses in the country no less than in the city ought to wear what is most suitable for their work. For this purpose nothing can be better than the gingham dress, the long and high apron and the muslin cap. Be- cause of its appropriateness, this 32 A New Way of dress has become distinctive of nurses; that is, it is now their uni- form. It may well be varied in unimportant details to distin- guish the different training schools. But the uniform should be worn by every student-nurse after her term of probation. It will constantly remind her that she has been enrolled in the ranks of all who have been trained, and are still in course of training, for the noble profession she has cho- sen. And it is a great aid in making oneself more and more worthy, to feel that one's work is connected with the famous work of others, and is a part of the glo- rious whole. Another custom of the larger Training Nurses. 33 schools, which even the smallest training schools must follow, is the promising of diplomas to all who successfully complete the prescribed course of training. The diploma is a certificate of the nurse's faithful preparatory work and also of her fitness. The time will soon come when such a diploma will be as indis- pensable to a nurse's success as it now is to a physician's. Nurses already recognize its value, and the promise of it to those who fairly earn it is an incentive that ought not to be withheld. THE TRAINING OF NURSES IN PRIVATE PRACTICE. THE TRAINING OF NURSES IN PRIVATE PRACTICE.* There is a widespread belief that in sickness as much depends upon the nurse as upon the phy- sician. This belief is founded partly upon fact; for the nurse is the physician's lieutenant, and, of course, it is of as much im- portance that the medical orders shall be properly executed as it is that they shall be properly * Read at the Annual Meeting, June 8, 1887, and repub- lished from the Medical Communications of the Massachu- setts Medical Society. 38 A New Way of given. But such comparisons evince entire ignorance of the physician's responsibilities. It is his duty not only to give proper directions for the management of every patient under his charge, but also to see that his orders are intelligently obeyed. There is no excuse for him in the fact that trusty agents are not at his hand; for it is his business to provide them, and until he can be sure of intelligent, faithful nursing ser- vice, he must not undertake the management of more cases of sickness than he can in person superintend. Where the family or the friends of the patient undertake the nurs- ing service, the physician is par- Training Nurses. 39 tially relieved of responsibility for any improper execution of his orders. It is his duty, however, in such cases to point out the dis- advantages of such untrained nursing, if discovered, and to be then ready to supply suitable nur- ses if wanted. In times of war and in the hos- pitals this need of trained nurses has been recognized and met. Thirty-three years ago the Cri- mean war.gave to the world Flor- ence Nightingale, and now, under the banner of the Red Cross, her followers stand ready in every civilized country of the world to imitate her immortal example. Twenty-five years ago the New England Hospital for Women 60 A New Way of and Children began in this country the training of nurses ; and now scarcely a single hospital can be found that is not reaping the advantages of trained nursing service. Nor are these advan- tages limited to the hospitals. Trained nurses find an increasing demand for their services in pri vate practice. In no other depart- ment of labor is the standard of excellence so rapidly rising. Nurs- ing is already a profession, and no longer a trade of last resort. One result of this improved nursing service, and of the increas- ing demand for it, is the high rate of wages that the graduates of the training schools find no difficulty in obtaining at the very Training Nurses. 61 beginning of their private prac- tice. Only the more wealthy families can as yet afford to em- ploy them. The whole question of wages, however, depends upon the proportion of the supply to the demand. And families in moderate circumstances will not be able to have better nursing service until the supply of trained nurses exceeds the present de- mand for them. When that oc- curs the present prices will fall, and nurses on graduation from the schools will have to be con- tent, as have young members of every other profession, to begin at the bottom, and not, as at pres- ent they can do, at the middle of the ladder of earnings. 62 A New Way of Inasmuch as by far the greater part of our practice is among that class now deprived of the improved nursing service, ought we not to take measures to supply the increasing demand for it, and to further the spread of its great advantages ? It must be confessed that hith- erto the medical profession has not only not taken the initiative in this reform, but has even im- peded its progress. Training schools for nurses have been generally at first opposed by the hospital staffs; and the graduates of the training schools have often failed to satisfy the unreasonable expectations of the physicians first employing them. Undoubt- Training Nurses. 63 edly some of this trouble has been due to the fact that the physicians - have been only indirectly con- cerned in the nurses' training and, accordingly, have not held them- selves responsible lor the nurses' advancement after graduation. Nor has it been thoroughly un- derstood that the training the new order of nursing rests upon is de- signed simply to furnish intelli- gent lieutenants. Without ex- plicit orders, correcting criticism, and the encouragement of con- fidence, very likely the old-time nurse will do as well as the best trained nurse. On the other hand, it cannot be denied that the trained nurses on leaving the hospitals have 64 A New Way of shown an inability to adapt them- selves to the varying service of different physicians, and to the circumstances of private practice. This fault is evidently due to the present methods of training, and can be remedied by sending the student-nurses out into private practice, under physicians whose co-operation in their training can be secured. But it is surely unnecessary at this day to dwell upon the slight disadvantages of the new order of nursing. And it is not so much the purpose of this paper to dis- cuss the possible improvement in the training schools as it is to de- monstrate the way in which the supply of trained nurses can be Training Nurses. 63 so increased that their services may be had in every village of the land. At present they can be had only in the larger cities, and even there only the rich can afford their services. Their num- ber, it is true, slowly increases, but not nearly as many nurses as physicians are graduated each year; while, in order to supersede the untrained nurses, it would be necessary to provide probably three times as many trained nurs- es as there are physicians depend- ing upon their services. It is evident that this large supply, which must be provided before their employment becomes gen- eral, cannot be furnished by the present methods of training. The 66 A New Way of schools connected with the hos- pitals can train each year only as many nurses as are needed for the work of the hospitals,— a number much less than that of the yearly graduates in medicine. If, then, new methods of train- ing must be adopted, in order that the growing demand may be met, and that even in the families where the income is small the patient and the' physician may have the great advantages of trained nursing service, it is sure- ly incumbent upon the medical profession to devise and to inaugu- rate these new methods of train- ing. This duty rests primarily upon the country doctors. In the larger cities the hospital train- Training Nurses. 67 ine schools can furnish nurses for the wealthy, and physicians can send their poorer patients to the hospitals, or avail them- selves of the excellent system of district nursing—the latest flower in this spring-tide of charities. But in the smaller cities, and in the towns and villages, the physi- cians, if they desire the great advantages of this new dispen- sation, must train their own nurses. It is one of the many new duties that have fallen up- on the medical profession; and it is therefore desirable to have some general plan for its per- formance. Fortunately, there is no trouble now-a-days in finding young and 68 A New Way of strong women well fitted and eager for such training. The schools in operation have long lists of applicants who wait their chances to enter. Let it be known in any community that the physicians contemplate insti- tuting a training school, and can- didates in plenty will come for- ward. But they have read " Sister Dora," and perhaps Florence Nightingale's famous " Notes," and although they would prefer not to leave their native towns and their friends, they nevertheless desire thorough training. They stand precisely where the would- be doctors stood a hundred years ago, before medical schools were to be found: they want the Training Nurses. 69 physicians to teach them. They will gladly work hard for wages that will barely support them, they will gratefully give to the physicians most loyal, hearty ser- vice, if meanwhile they can be learning the art of nursing. Let us consider how this should be taught. From the general similarity of the two professions of nursing and of medicine it is evident that, for excellence in either, much the same kind of training is requisite. The difference between them, however, relieves the nurse of the responsibility of deciding what is the nature of the patient's trouble, and what should be done to re- lieve it: her only duty is to carry 70 A New Way of out the treatment ordered, and to note the different symptoms as they occur. The nurse, then, may well be ignorant of the theory, but she must be somewhat ac- quainted with the practice of med- icine. She need not know in any given case why catharsis is advisable, but she must know what to expect when a cathartic is given. The only exception to this gen- eral rule is in the matter of emer- gencies. In this department it is necessary to drill the nurse so thoroughly that she will always have her wits in good working or- der, whatever her patient's danger may be. There is no use in expect- ing her to remember blind rules. Training Nurses. 7/ She must be taught the princi- ples upon which the rules depend. Better far that the nurse shall remember the blood-starved con- dition of the brain in syncope, than that she should remember any rule for its relief. She must understand the underlying princi- ple if common-sense treatment is expected of her. But training for emergencies happily demands only a small frac- tion of consideration. In order that the nurse in general practice may be able to carry out the medi- cal orders intelligently, and report intelligibly the changes that take place during the physician's ab- sence, she must have a working knowledge of elementary ana- 72 A New Way of tomy and physiology ; of the gen- eral progress of the common diseases ; and of the effects of the more powerful drugs. Stu- dent-nurses should therefore be taught enough anatomy that they may understand the general work- ings of the body, and be able to use and to understand anatomical terms descriptive of the body's surface. Some knowledge of the structure and function of the lungs, for instance, is prerequisite to any satisfactory realization of the necessity of pure air. And it is a matter of more than mere convenience to all concerned that the nurse and physician shall be able to understand each other's use of the words stomach and abdomen. Training Nurses. J3 In the hospital training schools the student-nurses may perhaps safely be left to learn what it is important for them to know about the different diseases, as these diseases are met in the wards; but in the country schools, where the nurse's experience is more slowly acquired, they must be taught, before the disease is met, its general characteristics. The special nursing required in typhoid fever, for example, must be taught beforehand if the nurse is expected to take the best care of her first typhoid patient; and this can best be taught by de- scribing the nature of the disease. The medical student is taught not only how to treat but how 74 A New Way of to diagnosticate diseases that he has never seen ; and there is no reason why nurses should not likewise be taught the special nursing needed in diseases they have not seen. As regards materia medica it is not so plain how much and how little nurses should be taught. The bugbear of the nurse's med- dling in the physician's province must not prevent her being taught at least enough about drugs to prevent her from making grave mistakes in administering medicine. Not only is it con- venient but it is often necessary to leave medicine, opium for in- stance, in the nurse's hands to to be given pro re nata or si opus Training Nurses. 75 sit. In such cases the nurse must be able to recognize the effects of the drug, and also the indi- cations for its use. There is no danger of the trained nurse's knowing too much, and the more knowledge of medicines she ob- tains the less likely will she be to attempt to prescribe them. The instruction in these branches, if it is to be as systema- tic as it should be, must be given by the physicians in regular lesson hours. The student-nurses can be assembled at their head- quarters on certain afternoons or evenings. And except when in charge of the very sick it is a ben- efit to both nurse and patient for the nurse to go out for the fresh- j6 A New Way of ening walk and for the stimulus that the lesson gives. And again, these meetings of the student- nurses with the physicians are beneficial to both. The nurse feels her instructor's interest in her advancement, and shares somewhat the enthusiasm of his high calling. The physician, on the other hand, finds it not in the least a disadvantage to be thus forced to review his foundation studies; he acquires a higher ap- preciation of the importance of the sister-art of nursing; he can realize and sweep away the ob- stacles to the nurse's success. A good working basis for both is thus established, which in times of anxious watching brings forth Training Nurses. 77 the fruit of comfort a hundred fold. * Besides this groundwork that nurses should be taught by their medical instructors, the arts of cooking for the sick, and of keep- ing the patient and the sick chamber in exquisite order, must be taught them by women who are themselves proficient. The multitude of little ways of giving comfort to the sick, discoveries accumulating rapidly and being disseminated by books, and now also by the nurses' journal, " The Nightingale," can after all be best taught by actual example. In these exceedingly important branches of the nurses' training, the students in the hospital train- *]8 A New Way of ing schools have the advantages of working with trained nurses and also with nursing their pa- tients in surroundings especially adapted for the purpose. This latter advantage can be had in the country training schools by making a miniature hospital out of some tenement where a few patients may be collected. And it is absolutely essential in the country training schools to have at least the partial service of a trained nurse in teaching others to be nurses. Such a teacher can be the queen of the miniature hospital, and at the same time, at the option of the physicians, can follow them on their rounds, visit- ing the bedsides where the stu- Training Nurses. jo dent-nurses are employed, to teach them there whatever in her more experienced eyes is needed. In times of unusual healthful- ness, the superintendent nurse can teach them how to write good clin- ical reports, how to take the tem- perature and pulse, and how to read aloud acceptably. The books upon nursing can then be studied. Upon an improvised manikin, bandaging, fomenting, poulticing can be taught. And upon each other the student- nurses can practice massage. This is a general outline of what every nurse should be taught. But the profession of nursing has already divided itself into special- ties. That of nursing the insane / 80 A New Way of can be taught only in the asylums, for physicians themselves have to look thither for the glimmer- ing light of what little has yet been discovered about the com- forting care of minds deranged. It is a matter for general rejoic- ing that the training school at the McLean Asylum, the pioneer school of its kind, is already fur- nishing trained nurses for these saddest cases. Monthly nursing, however, will always be the chief specialty, and in no other department is trained service so fruitful of com- fort and security. I need not set forth again in detail what month- ly nurses should be taught, for I have done that in my manual Training Nurses. 81 upon the subject, but I want to call attention to the excellent op- portunities physicians have in their private practice to train nurses in this branch. And, after once showing the student-nurse how to prepare the bed and how to dress the patient, how after delivery to remove all traces of the labor, and how during the confinement to manage the little details of bathing, giving enemas, catheterizing, bandaging the breasts, etc., the physician's work becomes delightfully light- ened. Nor only this: his patients also are relieved in large part of the usual annoyances and ugly features of midwifery cases. This general plan of a new 82 A New Way of kind of training school is no longer visionary. Such a school is already in most successful oper- ation in Waltham, the youngest city of Massachusetts. Its first class has lately been graduated. It is not fitting for me to sound their praises; nor need I here, for they have already won honorable mention in the service of many members of this Society. But as an illustrative case, as a demon- stration of the feasibility of the plan, attention is called to the history of the Waltham Training School. It is not, however, because of its financial success that claim for attention is made; nor because of the deeply gratifying effect Training Nurses. 83 that such training has upon the student-nurses in bringing out into perfect blossom their latent womanhood. For in both of these directions great success has been before recorded. Atten- tion is called to the Waltham School because it is felt that a great and general want has been there fully supplied. Nurses are now at hand for any emergency. The physicians have only to call, and the nurses come, — to give their orders, and they are obeyed. In destitute families, where hitherto the hard alternatives have been for the physicians to do the nursing service themselves, or to let the cases go from bad to worse through default of proper 84 Training Nurses. care, the student-nurses now go gladly for day or night service to carry into effect the physician's good intentions. It is in this kind of service that full warrant is found for appealing to the charit- ably inclined for the little money that is needed to establish such training schools. HISTORY OF THE WALTHAM TRAINING SCHOOL FOR NURSES. Read at the Annual Meeting of the Middlesex South District Medical Society, April 18, 1888. THE WALTHAM TRAINING SCHOOL FOR NURSES. In order to understand the benefits of any innovation it is well first to review the former state of things. Let me describe, then, the kind of nursing service that we endured here before the training school was started. After- wards we will consider the school's growth and the advantages of the present service. Three years ago it was hard to find a nurse. The different physicians kept lists of all the nurses they knew or had heard of; 88 A New Way of and, when one was needed, the husband or some other friend of the patient, armed with this list of addresses, was sent out on a nurse hunt. Meanwhile the physician would stand guard over the patient. Many a time it happened that the hunters would come back unsuccessful. At one house the nurse or some one of her family was sick, and she could not leave ; at another place the family knew nothing of the nurse's whereabouts; at several other places it would be found that the nurses were out at service, or that they could not go out as they were expecting calls which they had engaged to answer. Training Nurses. 89 No wonder, after a long series of disappointments, that the seekers, knowing nothing of a nurse's proper qualifications, would gladly engage the first woman who would agree to come. No matter how unfit for nursing the physician might know her to be, not able himself to provide a better nurse, he would have to swallow his ob- jections. Frequently, from the moment of the nurse's entrance, the physician would have the double duty of looking out for both nurse and patient. If he succeeded in securing the main requisites of fresh air, suitable food, and necessary quiet, for his patient, it was only by dint go A New Way of of hammering down the nurses prejudices and notions. What- ever account he might get of his patient's condition in the inter- vals of his visits would have to be extorted by cross-questioning the nurse. Her opinions, however, both as to diagnosis and prog- nosis, were always generously given. Her ideas also of what the treatment should be, or of what Dr. So-and-so used to do in just such cases, were often venti- lated. Not seldom, owing to the variance betwixt the physician's ideas and her own, the treatment ordered would not be carried out, and that, too, when it was well within her power to obey. When it came to applying Training Nurses. 91 poultices or fomentations, to giving enemas, douches, massage, or even sponge baths, properly, the physician himself would have to attend to the administration of them. Antiseptic precautions on the nurse's part were wildly out of the range of possibilities. Time need not be taken for further details of the disadvan- tages of the former kind of nurs- ing. To a greater or less extent the same disadvantages still ob- tain wherever trained nurses may not be had. It is true that in the case of wealthy patients we en- joyed occasionally the service of nurses graduated from the Bos- ton training schools, and also of untrained nurses who did fairly 92 A New Way of well. But these happy experi- ences served only to enforce the fact that the greatest obstacle to an improved practice of medicine, of surgery, and especially of mid- wifery, was the lack of suitable nursing service. At a meeting of the resident Fellows of the Massachusetts Medical Society, in February, 1885, I had the honor of propos- ing a plan for supplying the great need we all felt. My proposition was cordially acted upon, the scheme was soon in operation, and its success has far exceeded our most hopeful expectations. A brief account of our training school was given in my paper on "The Training of Nurses in Pri- Training Nurses. 93 vate Practice," read at the last annual meeting of our parent so- ciety. And now this more com- plete history of the undertaking is laid before you, for the proof that it gives that similar under- takings may succeed elsewhere. The Waltham method is based upon the facts, first, that nurses can be well trained in private practice, outside of hospital walls, and second, that excellent service is given by the student-nurses during their course of training. Heretofore the training of nurses has been undertaken only in connection with hospitals, and then only to the extent that the service of the hospitals demanded. Our method is a recourse to the 94 A New Way of old way of training physicians, where the medical student worked with his preceptors, and only in- cidentally attended courses of lec- tures and examinations in order to get his diploma. For physi- cians a more theoretical education became necessary. But for nurses, who have no need for theories, but rather for drill in the execu- tion of the physician's orders, this discarded method is just suited. It is even better than the customary training given in hos- pital wards, for hospital prac- tices are very different from what necessarily obtains in private sick chambers. Moreover, in the wards the' nurses receive their orders through the Head Nurse Training Nurses. 93 and are not brought into direct working relation with the doctors, as they must be in private prac- tice. It is true that we now have a small hospital, which gives em- ployment to perhaps a fourth of the student-nurses by turns; but for the first year of the training school we had nothing of the sort, and during the second year we had here only a small private hospital, which only last fall was enlarged to its present not exten- sive dimensions. So, what train- ing our nurses have received has certainly for the most part been o-iven them in our private prac- tice and at the homes of our patients. g6 A New Way of Another feature of the Wal- tham method, which distin- guishes it from others, is the large amount of didactic instruction that is given. In other training schools only a few lectures are given to the nurses, perhaps one a week,— reliance being placed almost wholly upon the lessons that may or may not be learned in the wards. But in this school systematic and thorough instruc- tion is given to the nurses at the class room in the principles upon which the art of nursing depends. For nine months of their first year the student-nurses assemble for these lessons for an hour five afternoons of the week. Each physician meets the class once a Training Nurses. 97 week or fortnight, to give instruc- tion by a lecture, recitation or conference, upon the subjects as- signed to him. So far as is prac- ticable, the experiences of the week serve as a basis for this instruction ; but the nurses are taught what their duties will be in the various cases they may be called to nurse. For instance, perhaps before ever they have seen a new-born baby they will have been taught just how to wash and dress it, not by having memorized blind rules, but by hav- ing had explained to them the reasons for the different steps in the process. In like manner they are taught what precautions to take in the g8 A New Way of care of cases of infectious disease. The principles upon which de- pends the antiseptic treatment of wounds are taught them. They are shown by chemical experi- ments what the difference is be- tween oxygen and carbon dioxide, when the importance of proper ventilation is urged upon them. They are also thoroughly taught massage, bandaging, cooking for the sick, bed-making and other like essentials of the art, by ex- perienced teachers, who volunteer their services or are specially employed. These lessons are given to them for the most part beforehand. They then take hold of actual work intelligently, which must ever be the ideal result to be aimed at in all teaching. Training Nurses. gg These frequent meetings of the class with the physicians estab- lish a most serviceable relation of mutual confidence. The phy- sician knows how far he can trust to the nurse's knowing what to do, and to her asking him for in- struction beyond this limit. At first it seemed possible to take as students some of the nurses who were then in the field. But they for the most part were women well past the prime of life, and we were already discour- aged by the difficulty of teaching old nurses new tricks. Nor could they afford to lose their wages for the two years of our course of training,— for they had taken up nursing, not for the love of it, ioo A New Way of but for the money to be made out of it, and generally as a trade of last resort. It was therefore decided to accept the applica- tions only of such young women as were willing to undertake a two years' course of training, and to give us their entire time in return for their instruction, their board, and an allowance for their neces- sary expenses, of nine dollars per month for the first year, and for the second year twelve dollars per month. Three ladies kindly consented to co-operate with us in the un- dertaking. After the success of the school was demonstrated, the lady managers at our request assumed the whole responsibility, Training Nurses. 101 except in the matter of teach- ing, which is still in the hands of the physicians. The school began in April, 1885, with a class of seven stu- dent-nurses, three of whom were graduated at the end of their second year. One, by reason of a long sickness, dropped back into the next class. One, after a few sorry months, was obliged to leave the school because of ill health, which would have pre- vented her acceptance, had we at first recognized the prime import- ance of good health as a quali- fication for admission. Another was discharged in disgrace, after nearly two years of deception, which might perhaps have been 102 A New Way of avoided had we at first inquired so particularly as we now do con- cerning the character of all appli- cants. The last one of the seven to be accounted for was called out to California during her first year, to nurse her sick brother. She has done nobly there, and we were proud to send to her a diploma in return for excellent reports of her cases. A second class, numbering eight, was started in October, 1886, although some of them really entered the school before that time. No mistakes were made in their selection, and no accidents have befallen them. The third class now numbers nine. Thirteen were taken in- Training Nurses. 103 to the school, but three resigned during or shortly after their month of probation; and one, a most promising woman, fell a victim to diphtheria, contracted while nursing a case of that di- sease. Counting the graduates, who make their headquarters here, and the student-nurses now in course of training, there are twenty; and yet, so great is the demand for them, it sometimes happens that not one can be furnished even to the physicians connected with the school. The following table shows how the demand has increased and in what proportion to the supply. 104 A New Way of Nurses ready for service. Nurses were employed. Percentage of employment. ist year . . 2,008 days 1,207 days 60.11 2d " . . 3,483 " 2,448 " 70.28 3d " • • 4,357 " 3,032 " 69.59 No account is made in the above table of the almost con- stant employment during the last year of the three graduates of the school. During their first year the stu- dent-nurses are employed only by patients of the physicians who are instructors in the school; and, on account of their hav- ing to assemble at the class room nearly every afternoon, it is of course impossible for them to serve at houses beyond easy walking distance. In the second Training Nurses. 103 year they are sent wherever called, often miles away, excepting that for the last month of their two years' course they are called in, and are then required to review the instruction they have received and to pass satisfactory examina- tions in every branch before they receive their diplomas. This extension of their field of service during their second year is of no small value in their training. For, while still only student-nurses, they thus serve under many different physi- cians, whose criticisms the mana- gers of the school request a-nd make use of in perfecting them. That the student-nurses give satisfaction is attested by the grow- io 6 A New Way of ing demand for their services. From the first, we have had in contemplation the establishment of a Registry for Nurses, in order to facilitate their wider employ- ment. But not yet is the sup- ply sufficiently greater than the local demand to make necessary or even feasible any attempt of this kind. All that can be said now is, that if possible a nurse will be sent by the school in answer to any request; but no promise can be made except on definite engagements. Let us now consider the growth of the school from the Treas- urer's point of view. Unlike many other reforms, this one pays its way, as may be seen in the following table : Training Nurses. ioj Expenses. Dona-tions. Earnings. Balance at end of year. ist year 2d " 3d " $1,051 76 2,656 54 3,300 18 $233 °° 358 7° 193 °° $888 40 2,407 61 3,004 12 $69 64 179 44 410 21* Totals $7,008 48 $784 70 $6,300 13 $659 26 Favorable as these figures are, no mention is made of the prop- erty now owned by the school. A dormitory and a class room have been completely furnished, at an expense exceeding the entire amount of the donations to the school. Nor is any mention made by the Treasurer of the large amount of gratuitous nurs- ing service that has been en- joyed, not only by those who were unable to pay for it, but * Includes bills receivable, amounting to $333-86. 108 A New Way of also by the physicians and their families. The writer, for his part, can never sufficiently express his gratitude for the many weeks of faithful nursing thus given to him. Farther details concerning the management of the school may be found in the appendix to this pa- per, and it now remains only to sum up the advantages of the new dispensation. First, as regards the supply. Nurses are now at hand. There is no more of the old-time hunt- ing for them. Instead, applica- tions, even by telephone, at the headquarters of the school are immediately answered by dis- patching a nurse to the house of need. Besides the great con- Training Nurses. log venience thus afforded, the physi- cian is thereby in position to dic- tate just what the nursing in any given case shall be. If he is not satisfied with a nurse, he can send to the school for another. If more than one is needed, as in more serious cases, he can have two or three who will pull well together. Or, if he wants a nurse for one night, or for an hour only, he has only to call for one. In his practice he is thus relieved of the strictly nurs- ing details which formerly took so much of his time and strength. Nor need the physician consider whether his patients can afford to have nurses. For at his appli- cation the nurses are sent to no A New Way of nurse the poor as well as the rich. Second, as regards the fitness of these new nurses for their work. Better nurses cannot be found. And this is the testimony not only of the physicians who employ them: it is even more em- phatically so testified by the pa- tients who have enjoyed their kind and skilful ministrations. They do their work with all their heart and soul. They rejoice at every summons. Often they prefer to be called to nurse the very poor. And they ever carry with them comfort and sunshine. Training Nurses. in APPENDIX. The following description of the school and list of questions to be answered, is sent to all appli- cants. WALTHAM TRAINING SCHOOL FOR NURSES. The course of training occupies two years and begins each year October ist. It includes instruction by lectures and by care of patients in the Hospital and at their homes, wherever these may be, whether of comfort or of poverty. Appli- cants for the course should be between the ages of twenty-one and thirty-five- They must possess a good common school education, physical capacity to undergo the labor and fatigue connected with the profession of a nurse, and must present a 112 A New Way of certificate from some responsible person as to their good character. After ap- proval by the committee of the Board of Managers, they are received for one month on probation. During this month they receive board and lodging, but no compensation. At the end of this proba- tionary month their fitness for the work and the propriety of retaining or dismiss- ing them is determined by the Instruct- ing Physicians, the Superintendent and the Managers of the School, and the same authorities can also discharge them at any time, in case of misconduct or ineffici- ency. Those admitted for the full course as student-nurses must sign an agreement to remain in the school and submit to its rules for two years from the day of en- tering. Instruction will be given on the subjects of anatomy, physiology, mid- wifery, hygiene, bandages and dressings, food and medicine, all care of patients and patients' rooms, the best method of rub- bing and exercising the sick, the prepara- tion, cooking and serving of nutritious and appetizing food. Board and lodging will be furnished throughout the course, and Training Nurses. 113 residence at the school will be required of the student-nurses, when not at service, unless otherwise ordered. A monthly al- lowance of $9 for the balance of the first year and $12 for the second year will be paid them for personal expenses, wash- ing and text-books. This sum is in no- wise intended as wages, it being consid- ered that their education during this time is a full equivalent for their services. Two weeks' vacation each year will be given without forfeit of allowance; if longer time is taken a deduction will be made. The school provides for each nurse the caps needed, four white aprons and material for four plain gingham dresses. The students will themselves provide what further may be needed. All under-cloth- ing must be perfectly plain, and plainly marked, and colored skirts be made of wash material. Fifty cents a week will be charged for laundry work for each nurse. This allows twenty-four articles of plain clothing, including one dress'but no long white skirts. In case of disin- fecting after contagious disease one en- tire change will be allowed without laun- dry charge. 114 A New Way of Rules. I. The student-nurses are subject to the control of the Superintendent of the school, who, in case of misconduct, can suspend them from duty, and will then re- port the case to the Managers for final determination. II. During the first year the student- nurses must hold themselves in constant readiness to answer immediately all sum- mons to service under the physicians con- nected with the school, and will be re- quired, except in cases of extreme need, to be promptly present at the class les- sons five times a week. III. During the first year the student- nurses will be called to service in rota- tion, and throughout the course the man- agement will strive to equalize the service. During the second year they may serve in or out of the city, and under physicians not connected with the school. IV. When at service the school uniform must be worn. V. The student-nurses will be expected to prepare, when possible, and to serve the food for their patients. Training Nurses. 113 VI. Examinations will be held from time to time to test the proficiency of the student-nurses, and to those satisfacto- rily completing the course the diploma of the school will be given. It is expected that nurses will bear in mind the importance of the duties they have undertaken, and will evince at all times, self-denial, forbearance, gentleness, kindness and good temper. When nurs- ing in families where there are no ser- vants, if their attention is not of neces- sity wholly devoted to their patient, they are expected to make themselves gene- rally useful. They are to be careful not to increase the expenses of the family. They are most earnestly charged to hold in sacred confidence the knowledge which, to a certain extent, they must obtain of the private affairs of such households or individuals as they may attend. 116 A New Way of These questions are to be answered in the applicant's own handwriting and sent to the Stiperintendent, Training School for Nurses, Waltham, Mass. i. Name in full and present address of applicant. 2. Are you a single woman or a widow ? 3. Your present occupation or employ- ment ? 4. Age last birthday, and date and place of birth ? 5. Height and weight ? 6. Where educated ? , 7. Are you strong and healthy? and have you always been so ? 8. Have you any physical defect ? 9. If a widow, have you children ? How many ? Their ages ? How are they provided for ? 10. Where(if any) was your last situation? How long were you in it ? 11. The names in full and addresses of two persons to be referred to. State how long each has known you. If previously employed, one of these must be the last employer, one of them shall not be a relative. 12. Have you read and do you clearly un- derstand the regulations ? I declare the above statement to be correct. Date, Signed, Applicant. A physician's certificate, as to health and strength, is required of those applying by letter. Training Nurses. iij In order to insure a perfect un- derstanding between the mana- gers and employers of the student- nurses a circular containing the following information is sent to each employer: Student-nurses of the first year are re- quired, except in cases of extreme need, to be promptly present at the class lessorrs from four to five P. M. five days in the week. The charge for these nurses is $1.25 per day and board, or $7 per week and board. The charge for student-nur- ses of the second year is $1.50 per day and board, or board and $10.00 per week. Where it is not convenient for the family to furnish board it will be provided by the school, at a charge of 50 cents a day. The charge for night watching is $1.50 a night. When an engagement is made, half price will be charged after the en- gagement begins until the time of actual service. During this time of waiting the nurse may be in the family if desired. 118 Training Nurses. When employed for less than a week, both days, the one on which the nurse enters her duties, and the one on which she leaves, will be charged. Travelling expenses are to be paid by the family em- ploying the nurse. If the nurse's wash- ing is done in the family, 50 cents per week will be deducted from the charges made. A bill for the amount due will be sent by the school when the service ends. The nurse must be allowed every day reasonable time for rest and recreation in the open air; also, except in case of extreme illness, opportunity to at- tend church once on Sunday. When employed for several consecutive nights she must have at least six hours per day out of the sick room. The nurse when on duty, will always wear the dress pre- scribed by the school. A few days' notice of the return of the nurse should be given, where possible, to the Superintendent. Any remarks as to the nurse's efficiency are requested, and will be thankfully re- ceived ; but it is also requested that they be sent directly to the Superintendent of the school, or to one of the lady mana- gers. s WORKS ON NURSING. A Century of Nursing...................... 50 Allan, Notes on Fever Nursing............ 75 Anderson, Medical Nursing............... 1.00 Bellevue Hospital Training School Man- ual....................................... 75 Brown, The Invalid's Tea Tray........... 50 Bruen, Outlines for the Management of Diet...................................... 1.00 Brush, Manual for Instruction of Atten- dants on Insane......................In Press. Chambers, Diet and Regimen.............. 2.75 Coles, Nurse and Mother, a Manual of Monthly Nursing........................ 1.50 Connecticut Training School Hand-book, 1.25 Cullingwortli, Manual of Medical and Surgical Nursing........................ 50 Monthly Nursing..................... 50 Domville, Manual for Hospital Nurses and Others Engaged in Attending the Sick, sth Ed., with Appen. and Glossary. 75 Dulles, What to Do First in Accidents and Emergencies. Illustrated, 2D Ed...... 75 Fotherjjill and Wood, Food for the Invalid...................................1.00 Graham, A Practical Treatise on Mas- sage....................................... 2.50 Handbook for Instruction of Atten- dants on the Insane, Prepared by a Sub- Committee of the Medico-Psychological Association............................... 1.25 Harris, The Nurse.......................... 60 Henderson, Diet for the Sick............1.50 Holland, Diet for the Sick. Notes, Medi- cal and Culinary....................... 50 Hood, Diseases and their Commencement. Lectures to Trained Nurses...........1.00 Jackson, J, C, How to Trbat the1 Sick Without Medicine....................... 225 Keating, Maternity, Infancy, and Child- hood...................................... i.oo Lietheby, Food............................... 2.00 Liiickes, Lectures on General Nursing... 1.00 ----Manual for Hospital Sisters......... 1.00 Mills, Practical Lessons in Nursing the Insane.................................... 1.00 Mitchell, S. W., Nurse and Patient....... 50 Nightingale, Notes on Nursing............ 75 Nursing, Handbook of...................... 1.2S Record for the Sick Room, designed for Nurses and Others Engaged in Caring for the Sick, per Dozen $2.50, per Copy 25 Smith, The Training of Nurses, 3D Ed., In Press. Storer, R. H., Nurses and Nursing......... 1.00 Suggestions for the Sick Room............2.50 Temperature Charts, per Package........ v> Thompson, Training School for Nurses, with Notes on Twenty-two Schools.... 60 Thompson, Food and Feeding.............. 1.25 ----Diet in Relation to Age and Activity, i6mo. Cloth............................. 50 Thomson, A. T., Domestic Management of Sick Room............................i.oo Weeks, Text Book of Nursing..............1.65 West, C, How to Nurse Sick Children__ 50 White, V., Manual of Nursing, Revised by Mrs. M. P. Jacobi .......................1.00 Wilson, Clinical Charts.................. 50 Worcester, Monthly Nursing.............. 1.25 ----A New Way of Training Nurses....... 50 *#* Any of the above books will be furnished post free on receipt of price by CUPPLES & HURD, 94 Boylston Street, Boston, Mass. MEDICAL WORKS PUBLISHED BY CUPPLES AND HURD, Publishers and Medical Booksellers, and Importers, g4 Boylston St., Boston, Mass. 80ST0N MEDICAL AND SURGICAL JOURNAL. Pub- lished weekly. Established sixty years. Edited by Dr. G. B. Shattuck. Yearly subscription, $5.00. Editorial communications should be ad- dressed to The Editor ; advertisements, sub- scriptions, and business letters to Cupples and Hurd, Publishers. SURGICAL CASES, with Illustrations. By Charles B. Brigham. 8vo. $1.00 THE MEDICAL REGISTER FOR NEW ENGLAND. By Francis H. Brown, M. D. A complete Directory and Guide. One vol. i6mo. Cloth, $2.50, net. *#* Published once in four years, the last edition issued April 1, 1888. CLINICAL CHART. For Hospital use. Records tem- perature, respiration, pulse, day of disease, date, age, diet, name, etc., Size 8x 10 in. Per dozen, 30 cts. Per gross, $3.00. FIRST HELP IN ACCIDENTS AND SICKNESS. A Guide in the absence or before the arrival of Medical Assistance. 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