# On Trained Nursing for the Sick Poor

FOR
PROVIDING TRAINED NURSES FOR THE SICK POOR.
ON
TRAINED NURSING FOR THE SICK POOR
BY
FLORENCE NIGHTINGALE.
A Letter addressed to The Times of Good Friday, April 14, 1876.
Printed by CULL & SON, HOUGHTON STREET, STRAND, LONDON, W.C.
For Providing Trained Nurses for the Sick Poor.
TRAINED NURSING FOR THE SICK POOR.
The beginning has been made, the first crusade has been fought and won, to bring—a truly 'national' undertaking—real nursing, trained nursing—to the bedsides of cases wanting real nursing among the London sick poor, in the only way in which real nurses can be so brought to the sick poor; and this is by providing a real home, within reach of their work, for the nurses to live in—a home which gives what real family homes are supposed to give—materially, a bedroom for each, dining and sitting-rooms in common, all meals prepared and eaten in the home; morally, direction, support, sympathy in a common work; further training and instruction in it; proper rest and recreation; and a head of the home, who is also and pre-eminently trained and skilled head of the nursing: in short, a home where any good mother, of whatever class, would be willing to let her daughter, however attractive or highly educated, live.
But all this costs money.
What a District Nurse is to be.
Allow an old nurse to say her word on this system, which ​twenty years ago was a paradox, twenty years hence will be a commonplace.
If a nurse has to 'find herself,' to cook for herself, when she comes home 'dog tired' from her patients, to do everything for herself, she cannot do real nursing; for nursing requires the most undivided attention of anything I know, and all the health and strength both of mind and body.
If, then, she has to provide for herself, she can only be half a nurse, and one of two things happens. Either she is of the level of her patients, or she sinks to the level of her patients, and actually makes apologies for their dirt and disorderliness, instead of remedying these, and instead of their making apologies to her, and being anxious for these to be remedied. Nay, as the old hospital nurse did thirty years ago, she may even come to prey upon what is provided for her patients.
There is a third alternative: that she breaks her heart.
But the thing which always does happen is, that no woman really fit for the work will do it, or ought to do it.
To have a person fit to live in a home—and who would have any other?—and to create homes for the poor, for it is nothing less, you must have a home fit for her to live in.
If you give nurses a bad home, or no home at all, you will have only nurses who will live in a bad home, or no home at all.
They forget what a home is.
How, then, can they reform and recreate, as it were, the homes of the sick poor?
The very thing that we find in these poor sick is, that they lose the feeling of what it is to be clean. The district nurse has to show them their room clean for once; in other words, to do it herself, to sweep and dust away, to empty and wash out all the appalling dirt and foulness; to air and disinfect, rub the windows, sweep the fireplace, carry out and shake the ​bits of old sacking and carpet, and lay them down again, fetch fresh water and fill the kettle; wash the patient and the children, and make the bed.
Every home she has thus cleaned has always been kept so. This is her glory. She found it a pig-sty; she left it a tidy, airy room.
In fact these nurses are so far above their patients, that the poor are 'ashamed that we should see their homes dirty again.'
One woman burst into tears as she said:
'It looks like it did before I was taken ill, and all my troubles came upon me; indeed I used to be clean and tidy, ask the neighbours if I wasn't; but what with sickness and trouble, I let one thing after another get behind, and then it was too much for me altogether. Why, I haven't been able to make my bed properly since I came out of hospital, for I did not seem to have heart or strength to do anything, but I will never let it get into such a state again.'
And she kept her word, the nurse helping daily in the heavier part of the work, when attending to dress the patient's wound, till the woman was able to do it all herself.
In another case, the mother had been two years in bed. The place was a den of foulness. One could cut the air with a knife. The nurse employed two of the little children to collect the foul litter and dirty linen from under the bed and sort it, emptied utensils which had not been emptied for a fortnight (this is common), cleaned the grate, and carried away the caked ashes, washed the children, combed and cleansed their hair, crowded with vermin. Next day, the eldest girl of eight had scoured the place and, perched on a three-legged stool, was trying to wash the dirty linen with her poor little thin arms. A woman, a neighbour, was found to do this.
But the highest compliment of all has to be told. In ​another den of dirt, Miss Lees, the 'head nurse' was proceeding, after the other most necessary operations, to wash a little puny boy, when he exclaimed: 'Willie don't like to be bathed. Oo may bath de Debil if oo like.' Such was Willie's opinion of the extraordinary powers of this new nurse: she could wash black white.
How has the tone and state of hospital nurses been raised?
By, more than anything else, making the hospital such a home as good young women—educated young women—can live and nurse in; and, secondly, by raising hospital nursing into such a profession as these can earn an honourable livelihood in.
If this is the case for hospitals, how much more so for district nursing, where the nurses have to be out in all weathers, and not in cab or 'bus, and where must be created, for there is not now, the esprit de corps which inspires the nurses of a good hospital and training-school as it does the soldiers of a regiment of many battles and well-worn colours whose glory has to be kept untarnished.
Even now, except in some remarkable instances, the hospital nurse wants more and gets less of the helps, moral, material, and spiritual, than the woman in a good home or service.
The district nurse wants yet more than the hospital nurse, for her life is harder and more exposed: and gets none.
Woman cannot stand alone (though for that matter, still less can men).
​Everybody knows how easy it is to sink to the lowest—'it is all the way down hill,' as I heard an old man say—how hard to rise to the highest!
A first beginning has been made to the district London nurse the real help and the real home which are the secret of the success of active religious sisterhoods abroad—together with he real independence, enterprise, indomitable pluck, self reliance, capability of training all the powers to the best efficiency, which are the secret of the success of the highest British character, and all of which are wanted in the crusade against dirt and fever nests—the crusade to let light and air and cleanliness into the worst rooms of the worst places of sick London.
To set these poor sick people going again, with a sound and clean house, as well as with a sound body and mind, is about as great benefit as can be given them—worth acres of gifts and relief.
This is depauperising them.
But to train and provide such District Nurses and such District Homes costs money.
What a District Nurse is to do.
A nurse is, first, to nurse.
Secondly, to nurse the room as well as the patient—to put the room into nursing order. That is, to make the room such as a patient can recover in; to bring care and cleanliness into it, and to teach the inmates to keep up that care and cleanliness.
Thirdly, to bring such sanitary defects as produce sickness and death, and which can only be remedied by the public officer, to the notice of the public whom it concerns.
A nurse cannot be a cook (though 'sweet Jack Falstaff' says she is), a relieving-officer, district-visitor, letter-writer, ​general storekeeper, upholsterer, almoner, purveyor, Lady Bountiful, head dispenser, and medical comforts shop. A District Nurse can rather less than a hospital nurse be all this. Though, where things are wanting and wanted for recovery, she or her Head knew how and where to apply for them. There are agencies for all these things.
'Upon the written order of the parish doctor, we generally obtain from the workhouse authorities, for those patients whose state requires such nourishment, a supply of meat, brandy, wine, &c., and when we have found a difficulty in obtaining these from the parish authorities, the clergy, district visitors, and charitable missions have supplied us with them, as well as with linen and other necessaries. In some cases the nurses have prepared such nourishment as beef-tea, light puddings, and cooling drinks at the homes of the patients; in others they have been prepared in the Central Home; but usually medical comforts of this kind have been made (as well as given) by the district visitors. In no case has any nurse given anything to the patient beyond the actual nursing rendered them; but if as a nurse I am capable of judging nurses' work, I feel I may fairly say that this service has been of a higher character than that rendered by any other nurses in the kingdom,'—Extract from First Quarterly Report of Miss Florence Lees, Superintendent-General.
One may pretty safely say that, if district nurses begin by giving relief, they will end by doing nothing but giving relief.
Now, it is utter waste to have a highly trained and skilled nurse to do this; without counting the demoralising and pauperising influence on the sick poor, who have too many such influences already.
How often a drinking man will go all to drink, if you support as well as nurse his sick wife, is perhaps little thought of—as also what efforts such a man will make not to drink, when his wife is sick, if you help himself and her; to maintain his independence—and if you make his home by cleanliness and care less intolerable.
​Perhaps sickness is sent for this very end; and you frustrate it.
The present Association wants to foster the spirit of work (not relief) in the district nurse, and for her to foster the same in her sick poor.
Nor are these District Nurses without hearing and receiving evidence that this spirit is now becoming really understood among their sick.
One poor old woman was heard saying to her younger neighbour: 'Them nurses is real blessings; now husbands and fathers did ought to pay a penny a week, as ud' give us a right to call upon they nurses when we wants they.'
This is the real spirit of the thing.
So nothing is given but the nursing, and some day, let us hope that the old woman's sensible plan will be carried out. In the meantime, nurses are nurses—not cooks, nor yet almoners, nor relieving officers. But if needed, they are procured from the proper agencies, and sick comforts made as well as given by these agencies.
(1) A District Nurse must first nurse. She must be of a yet higher class and of a yet fuller training than a hospital nurse because she has not the docter always at hand; because she has no hospital appliances at hand at all; and because she has to take notes of the case for the doctor, who has no one but her to report to him. She is his staff of clinical clerks, dressers, and nurses.
These District Nurses—and it is the first time it has ever been done—keep records of the patient's state, including pulse, temperature, &c., for the doctor. One doctor stated that he knew when an operation ought to be performed by reading the nurse's report on the case; another, that by hearing the nurse's history of the case, he found patients to be suffering from typhoid fever who had been reported as consumptive. ​And a hospital doctor, who had admitted patients into hospital with the nurses written history of the case, 'doubted if many of our medical students could have sent a better report.'
(2) If a hospital must first of all be a place which shall do the sick no harm, how much more must the sick poor's room be made a place not to render impossible recovery from the sickness which it has probably bred.
This is what London District Nurses do; they nurse the room as well as the patient, and teach the family to nurse the room.
And it requires a higher stamp of woman to do this; to thus combine the servant with the teacher and with the educated woman who can so command the patient's confidence as to let her do this, than almost any other work.
A well-known bishop, now on the bench, cleaned himself the pig-sties of the Normal Training School, of which he was master, as an example,—perhaps one of the most episcopal acts ever done.
(3) A District Nurse must bring to the notice of the Officer of health, or proper authority, sanitary defects, which he alone can remedy.
Thus dustbins are emptied, water butts cleaned, water supply and drainage examined and remedied, which looked as if this had not been done for one hundred years.
Hospitals are but an intermediate stage of civilisation. At present hospitals are the only place where the sick poor can be nursed, or, indeed, often the sick rich. But the ultimate object is to nurse all sick at home.
Where can the sick poor in general be sick?
At home: it is there that the bulk of sick cases are.
But where can nurses be trained for them?
In hospitals: it is there only that skilled nurses can be trained.
​All this makes real nursing of the sick at home the most expensive kind of nursing at present.
Yet no one would wish to convey the whole sick population into hospital, even were it possible, and even if it did not often break up the poor man's home.
In one case Miss Lees' trained nursing enabled the parish doctor to perform a very serious operation in the woman's own home, whereby the parish was saved a guinea a week, and the poor woman's home was saved from being broken up.
But all this costs money. The District Nurses cost money, and the District Home costs money. Each district nurse must have, before she is qualified:—
* A month's trial in district work.
* A year's training in hospital nursing.
* Three months' training in district nursing, under the Superintendent-General.
Each District Home must have a superintendent, who initiates and supervises the nurses' work. Moreover, only a limited number of nurses can be placed in one District Home, for more would be too far from their work. The multiplication of homes will cost money.
For anything like a 'National,' or even a 'Metropolitan' concern, a capital of £20,000 and an income of £5,000 a year are wanted.
Of this a great part is wanted at once—
    To set on foot three District Homes;
    To pay and maintain their superintendents, nurses and probationers;
    To create a hospital training-school in which to train.
What has been done at present to establish one District ​Home (which it is hoped will be the Central Home of many other districts) under the charge and training of Miss Florence Lees, as Superintendent-General, with five hospital-trained nurses and three nurse candidates, and to carry on the previously existing work of the East London Nursing Society with six nurses.
The Central Home was opened at 23, Bloomsbury Square in December last, the nursing work having been begun in the neighbourhood, from a temporary abode, in July. The Nightingale Training School at St. Thomas's Hospital is at present giving the year's hospital training to six, to be increased to twelve, admitted candidates.
A group of districts is now about to be nursed where the residents have engaged to raise £300 a year towards the expenses of a district home, with a skilled superintendent for supervising the nursing of four or more trained nurses, and one or two servants; for district nurses have quite other things to do than to cook for and wait upon themselves. They are the servants, and very hard-worked servants, of the poor sick.
We ask the public not to add one more charity or relief agency to the many there are already, but to support a charity—truly 'metropolitan' in its scope, and truly 'national' if carried out—which never has been before.
* ↑ To patients living up five or six pairs of stairs in Soho and St. Giles's the district nurse has often to go; the water tap is below the pavement in a celler; the dustheap in the basement, and sometimes below it; no dustpan or tins for fetching water. This is the room the nurse has to clean and purify. And she does it. These are the very triumphs of her art.
* ↑ All proper cases are removed to hospital: but some will not consent to go. And the large majority of these cases are cases which would not be admitted into hospital, e.g. consumption, incurable cancer, or paralysis, or ulcerated legs, &c., but would if not nursed at home, be sent, at the expense of the parish, into the workhouse infirmary.
* ↑ Experience hitherto shows that, if an institution is begun to 'provide skilled nurses for rich and poor,' especially if to be self supporting,' it ends by 'providing skilled nurses' for 'the rich' alone. For 'the rich' must come first, if the institution is to be 'self-supporting': or in other words, if the nurse is to 'support' the institution. And if the rich come first, they will be first and last.The present Association has therefore begun by providing trained nurses for the poor alone, always in the view of the Provident Dispensary System at last: also, of nursing pressing, needy, middle class cases, as already has been done.These, and indeed poorer cases, have made presents to the Association. the Nurses take none.But the object of the Association is: to give first-rate nursing to the poor sick at home (which they never have had). And this costs money.
This work was published before January 1, 1929, and is in the public domain worldwide because the author died at least 100 years ago.
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