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This we learn from the publication of the Proceedings for 1914 of the National League of Nursing Education. Agitation of these proposed changes has produced discussion in the General Medical Board of the Council of National Defense, and the attitude toward the question of creating a new class of nurses' aides or attendants is expressed by the following resolution:

“The committee believes that short-term courses are likely to result in positive harm. Their introduction into hospitals regularly maintaining training-schools would tend to break down the machinery of nursing education. Furthermore, the energies of women, who would otherwise take a thorough training which would make them more useful factors in the war, might be diverted to special short-term hospital courses.”

They also state: “We place ourselves on record as of the opinion that the mentally as well as physically sick should have the advantages of the services of a fully trained nurse." I would not undervalue training, as we have seen in the present war the uselessness and inefficiency of the amateur. (Out of 1500 women volunteers in a recent case of need—so Professor Stevens tells us-only two came forward in the real emergency.) The claim of full all-round training, however, for all may be regarded as a "counsel of perfection " when we reflect that not only is the supply of trained nurses insufficient for the needs of those in the community who are so fortunate as to be able to command their services. On the other hand, in private homes of the moderately well-to-do and in general hospitals, public and private, thousands are in equal need: yet the supply of graduate nurses is so limited that the creation of a body of less expensive trained“ attendants or “aides " seems imperative.

Furthermore, the state hospitals for the insane have at the most only an inadequate sprinkling of graduate nurses, a wholly insufficient body of pupil nurses, and are obliged to utilize as best they can the wholly untrained for the care of the great majority of their inmates. In institutions where a training-school is maintained, the number who complete their training, as compared with the demands, is insignificant. Those employed as attendants are a shifting body of individuals, only a small minority of whom can be said to possess the qualifications and the willingness to give themselves permanently to the duties of nurse or attendant upon the insane.

These facts make it necessary to consider whether a class of nurses of a grade less completely trained than the registered nurse and yet qualified for ordinary service, educated and standardized, and registered, or licensed by the state for their special field of usefulness, would not be an improvement upon the present rather chaotic condition.

Note.—Since the above was written, agitation of this subject has gone on apace. At the present time (February, 1919) there is heated discussion over a bill that the organized nurses have introduced in the Legislation of Illinois to create a body of "junior" nurses who shall have a course of 18 months' training. This law further provides that “a junior registered nurse may nurse the sick or disabled, but may neither engage in public health nursing, act in a supervisory capacity in a hospital or similar institution, act as an instructor or in a supervisory capacity in a school of nursing, nor act as an instructor or in a supervisory capacity in public health service or any other like service.” Moreover, she is not permitted to nurse in a hospital except " when she is under the immediate personal supervision of registered nurses" (italics mine).

This has the appearance of an attempt to develop an aristocracy or privileged class of nurses. The "junior" or "practical ” nurses will form a "middle class,” and it is to be feared the “proletarians” will come in and reduce the whole system to chaos !




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STATE HOSPITAL SOCIAL SERVICE SUGGESTED. The first statement that state hospitals might well broaden their field of activity or had come “ To the parting of the ways was delivered by Mr. Homer Folk, to whose foresight and constructive endeavor in many directions all state hospital people should be profoundly grateful. This warning fell from his lips nearly 15 years ago, when he stated as an opinion that the hospitals must broaden out and be powers for good outside their boundary lines else deteriorate with “ dry rot.” The suggestion met with favorable comment at the time and afterward, and yet one can survey the field to-day and see it has borne but little fruit. This is so because the visions of the idealist travel faster and farther than the material limitations of practical life allow. Ideals are like castles in the air, but they can be materialized if after dreaming them we get back to the brick and mortar of life and after removing obstructions build real castles patterned after the visions.

THE APPARENT ALTERNATIVE. Assuming that the plan has virtue in it, come back from the dream of the mental health exponent to examine the nature of the obstacles preventing the full development of the plan and study how to remove them; the alternative, quite impossible, seems to be to allow progressive tendencies to pass into other hands, for progression there will be. Within a few years social service has become recognized by departmental establishment in nearly 200 general hospitals of this country, and if the state hospitals fail to profit by this example and precedent the initiative will simply pass into other hands, leaving them more custo dial than ever.

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

PRACTICAL REASON FOR DELAY. Before a management can undertake to greatly enlarge its field of operations the feeling must be present that the base from which it operates is as safe and in as good order as the military base of an army commander. Very few hospital officers feel that way now, and while away from their institutions each man's head bears a crown of thorns. Under this condition of affairs can any such afflicted officer be expected to think seriously of the considerable expansion of his sphere of activity this plan entails? The answer, of course, is in the negative, so discussion of the cause of this disability, the ward service, is next in order.

The UNSATISFACTORY WARD SERVICE. All of us very well know that the attendant's calling should be considered a specialty of no mean importance. It is a trade or calling, the grasp of which demands several months' training. This has been fully recognized by superintendents these many years. Yet we know also that the ward employees are unstable as a class and in this fail to meet a fundamental requirement for good results. The training school for nurses was initiated 35 years ago to stabilize the service, but the result was achieved to minor (if not negligible) extent only. A questionnaire to show the figures concerning changes (and hence low efficiency) amongst ward employees was sent out just before the war and found the average number of changes in the attendant force in 60 hospitals in the United States and Canada was then no less than 75 per cent per year. Half of the attendant group changes several times per year. The replies therefore covered conditions very widespread, geographically and otherwise. Careful survey of the facts and figures makes the fact evident geographical location had little to do with the number of changes; neither did the size of the customary wages of $20 to $35; nor did the hours of labor have any bearing. The surmise that there existed some potent cause not yet fully recognized seemed well justified.

TEACHING SERVICE VERSUS CUSTODIAL SERVICE. The sceret was not deeply hidden, for some parts of the public service were more stable, and it simply became necessary to compare the facts concerning the relative services. Within the past few years it had been my fortune to go quite intimately into all of the state institutions of three states of the union and particular effort was made to ask concerning difficulties with attendants on one hand and teachers and guards on the other. It was soon found that the number of changes amongst state institutions employing guards for prisoners and teachers for boys and girls were far fewer than occurred amongst the attendants in the state hospitals. A little inquiry served to show that with practically equal working conditions the guards and teachers were better paid individuals and, on the whole, came from a more stable class of society, or else they felt that their reward for service was in proportion to the difficulties of said service. For one or both of these reasons the service in these quarters was certainly more smooth and harmonious and the end far better achieved.

QUESTIONNAIRE TO MID-West TEACHING INSTITUTIONS. The questionnaire recently returned from 18 institutions employing teachers and guards contained some interesting facts. Twelve concerned institutions employing practically all female help and six practically all male help. In the former group 420 employees showed 120 changes or 30 per cent per year as contrasted with 307 male employees with 114 changes or 37 per cent per year.

This indicates a somewhat higher rate of change amongst male employees. This is of particular interest as the females averaged $50 per month (and usually maintenance) and the males $70 per month (and usually maintenance). Therefore it would seem that a male wage of $70 is less satisfying than a female wage of $50. This is not surprising when we consider the customary additional burdens that the male of the species is expected to carry. Now to contrast the above with state hospital conditions we find a total of 727 teachers and guards with a turnover of 32 per cent in a year involving war conditions, whereas in the state hospitals we found a pre-war turnover of 75 per cent as something just ordinary and to be expected. With the plain fact here of twice the turnover in the state hospitals as compared with the others we find the wage in the state hospitals averages between $30 and $35 per month with the average in the other group nearly double, or $60 per month. Kindly

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