THE NURSING PROBLEM AS RELATED TO

PSYCHOPATHOLOGY.*

BY RICHARD DEWEY, A. M., M. D., Wauwatosa, Wis. With a view of eliciting discussion of the conditions and prospects in the sphere occupied by the immediate caretaker, nurse or attendant upon psychopathic patients, I will endeavor to state some of the elements and factors concerned in this particular problem.

First, a few words regarding the available nursing forces. Considered as a whole, this situation may be briefly outlined as follows: There is in the United States a total of between 80,000 and 90,000 registered or graduate nurses-the head of public health nursing at Simmons College, Anne Hervey Strong, puts the entire number at 66,000-of these 7000 are already enlisted in Red Cross War service and Surgeon General Gorgas is now asking for 5000 more. No one can forecast as to what the future has in store; but if the enemy is not overcome during the present year and if the victory is not obtained which alone can end the intolerable attempt of Germany to dominate and terrorize the world, we may see one-half of our entire force of nurses drawn into the employment of the military hospitals. The proportion of 12,000 nurses for each million of soldiers is considered requisite by the authorities. Accordingly, the present force of 1,000,000 soldiers requires 12,000 nurses; 3,000,000 soldiers would require 36,000 nurses. It is understood we face the possibility that even 5,000,000 may be required, which would necessitate a force of 60,000 nurses. To meet this demand, a school has been established at Vassar to which the Red Cross gave $75,000 and the government is planning an army school of nursing at cantonments. A 25 per cent increase of pupil nurses has taken place, but all that can be done will leave us short. Among our civil population, there are 3,000,000 persons sick and in need of nursing every day in the year, 90 per cent of these are in private homes. The loss to the nation in a year from this source is $1,500,000,000, and half of it is preventable sickness.

*Read at the seventy-fourth annual meeting of the American MedicoPsychological Association, Chicago, June 4-7, 1918.

Now, turning to the nursing problem as it affects our especial field: the state hospitals and those of county and city. We have a situation which can but occasion grave concern. Not only is there a dearth of trained nurses for mental cases, but nurses of any kind are in demand far in excess of the supply. The care of more than 200,000 mentally incompetent charges of the state rests upon the shoulders of the members of this Association. We have heretofore carried on our work, under difficulties to be sure of various sorts, with some degree of success, but the difficulties are now intensified many fold and also greatly heightened by economic stress. It is the general experience that there is a constant diminution of numbers caused by resignations of attendants and nurses from the service, while far less than the requisite number apply or can be found to take the places that become vacant. Many of us have found that neither "love nor money" appears to be of any avail and the necessity for help becomes more and more imminent. It has been our ideal to develop a body of trained nurses for our hospital work, corresponding in efficiency to the nurses of the general hospital. Training-schools have been inaugurated and maintained increasingly from the historic epoch nearly 40 years ago, when Edward Cowles established the first training-school for mental nurses in McLean Hospital (in 1880). The example of the McLean Hospital was followed in chronological order by Buffalo, N. Y.; Flatbush, L. I., N. Y.; Poughkeepsie, N. Y.; Indianapolis, Ind.; Kankakee, Ill.; and a constantly increasing number of training-schools has been developed. An effort has been made under great difficulties to maintain these schools, but, in general, they have fallen off in numbers and some have been discontinued. It has not been possible to reach a point of development where the whole body of the nurses and attendants could be carried through the complete course, and fewer still remain in the service after graduating. My own experience in maintaining a training-school at Kankakee from 1887 to 1893 convinced me that a full course of training for the whole nurse or attendant body, corresponding to the course given in the general hospital, was not practicable. In working upon a curriculum, especially adapted for the state hospitals, I found that the entire technique of surgical nursing and sick nursing could not be applied to the entire body of nurses. The field of nursing embraces

within itself many specialities: surgical nursing, sick nursing in all its varieties, the nursing of mothers in confinement and children, the nursing of the tubercular, public health nursing, massage and hydrotherapeutics; and, in departments by themselves, public welfare and social service. Finally, the care of mental cases is in itself a specialty requiring as much of study and talent, though of a different sort, as any of the others mentioned.

In the recent reports of two of the state hospitals of New Yorkthe Brooklyn and Manhattan hospitals-I notice particular mention is made of a special course of training covering a period of 13 weeks, which it has been sought with varying degrees of success to carry out with the general body of the nurses. A paper published in the Journal of the American Medical Association, by Dr. Philip King Brown, of San Francisco,' states that in 72 training-schools of California, mental nursing was only included in four. Dr. Brown's conclusion was that the present system of instruction is not well balanced. He recommends practical instruction in handling the sick, surgical cleanliness, administration of remedies and application of dressings, bath instruction and keeping of the chart. He is of the opinion that nurses should pay for their instruction and should not be boarded in the hospital.

In discussing training schools for state hospitals before the National Conference of Charities at Omaha, Neb., in 1887, the writer used the following language which may be regarded as still applicable to-day:

The training-school for attendants upon the insane, though in part an outgrowth of the training-schools for nurses, has an essentially different character-requires much that a sick-nurse does not need to know; while, on the other hand, much of the nurse's instruction would be thrown away on the asylum attendant. The persons who are willing to engage in the care of the insane as attendants do not possess the education and previous mental training which would be desirable, if attainable; and, therefore, their instruction must be of the most direct, plain and simple character.

Now, coming to the present day over a gap of 30 years, let us inquire: First, what are present conditions? Second, to what

'Journal of the Am. Med. Assn., May 18, p. 1438: "Nurses and the War," Philip King Brown, San Francisco.

extent the courses of instruction of the general hospital trainingschools is necessary to our especial purpose?"

We who have the field of mental nursing to occupy are all familiar with the embarrassment and lack of adaptation which the graduate of the general hospital training-school shows in mental cases, unless perchance she has gained experience in an institution for mental disease or had special training and instruction in such work. Indeed, the highly trained graduate nurse is often less fitted for oversight of the mentally deranged than many an untutored woman of common sense and kindly disposition. Who of us has not had nervous and psychotic patients or friends of patients who wished to avoid the trained nurse, who had such erroneous views that they objected to the very costume, and instead of being "healed" by the "seersucker stripes" were repelled? The well-starched cap and robe of white called up experiences in the past not of a pleasant sort.

Far be it from me to detract in the slightest degree from the conspicuous merit of the thoroughly accomplished and highly efficient presiding genius of the surgical ward, fever pavilion or operating room. I am only saying that the qualifications needed here are of another kind from those appropriate for dementia præcox or psychasthenia.

Here it is well to note the circumstances of a movement among the associations of trained nurses looking toward the formation of a class to be known as aides, assistants or attendants and to be auxiliary to the registered nurse.

In April, 1914, at a joint meeting of the American Nurses Association, the National Organization of Public Health Nursing and the National League of Nursing Education, these several bodies, representing about 50,000 nurses, passed resolutions requiring:

Ist. The acknowledgement of the necessity for two groups of nurses and no more: the trained nurse and the trained attendant. 2d. A pledge of cooperation in any plan which would provide suitable training for attendants.

3d. A belief in standardization and protection of the attendant by law.

2" Training-Schools for Attendants." Proceedings National Conference Charities, Omaha, Nebr., 1887, p. 221 et seq.