THE LANCET COMMISSION ON NURSING

[FEB.

28, 1931

THE LANCET COMMISSION ON NURSING centres an even larger number of variables exist. Some of these, it was hoped, might prove to be correlated with greater or less difficulty in securing recruits. Nature of Questionnaire.

training

FIRST INTERIM REPORT. 1. A COMMISSION

appointed in December, 1930, to inquire into the reasons for the shortage of candidates, trained and untrained, for nursing the sick in general and special hospitals throughout the country, and to offer suggestions for making the service more was

4. A Subcommittee was appointed to draft a questionnaire which was divided into a single sheet attractive to women suitable for this necessary work. (questions 1-12) sent to all the hospitals approached, and a double sheet (questions 13-36) sent only to hosThe members of the Commission are :pitals approved as training centres. For convenience, of ten different colours was used for the quesThe Earl of CRAWFORD and BALCARRES, P.C., K.T., paper addressed to different groups of hospitals F.R.S. (Chairman). which were classified :— Prof. HENRY CLAY, M.A., D.Se., late Professor of (A) According to the groups approved by the Social Economics in the University of Manchester. General Nursing Councils (Complete, Affiliated, Miss R. E. DARBYSHIRE, R.R.C., Matron, University

tionnaires

Associated, Reciprocal, Children, Fever, Mental).1

College Hospital.

(B) According to the simpler classifications of Miss L. CLARK, M.B.E., R.R.C., Matron, Whipps Special (excluding tuberculosis) and TuberCross Hospital. The among the non-approved hospitals. Dr. ROBERT HUTCHISON, F.R.C.P., Physician to the the other last-named was from separated group London Hospital and to the Hospital for Sick Children, special hospitals since there was reason to believe Great Ormond-street. that the staffing of hospitals and sanatoriums Prof. F. R. FRASER, M.D., F.R.C.P., Professor of was a specially acute Medicine in the University of London, Physician to problem. tuberculous patients St. Bartholomew’s Hospital. The method of selecting a fairly representativee Mr. A. LISTER HaRRisorr, J.P., Chairman, Comsample of the non-approved hospitals had then to be mittee of Management, Metropolitan Hospital. chosen. Various methods of selection were considered Miss M. D. BROCK, O.B.E., M.A., Litt.D., Headand discarded as unsatisfactory. It was eventually mistress, the Mary Datchelor Girls’ School. decided to send questionnaires to all hospitals, whether Mrs. OLIVER STRACHEY, Chairman, Employments voluntary or municipal, situated in counties with Committee, London Society for Women’s Service. names beginning with C, S, K, or M, being the Miss EDITH THOMPSON, C.B.E., Member of Council, initial letters of the names of the officers of the Bedford College, University of London. Commission. The lists from which these hospitals Sir SQUIRE SPRIGGE, M.D., F.R.C.P., the Editor of were taken were based upon information supplied THE LANCET, with Dr. M. H. KETTLE, an assistant in well-known reference books.2 Questionnaires were editor, as honorary secretary. also sent to a few hospitals in other counties for special reasons. In view of the possibility that 2. The Commission held its first meeting on tuberculosis hospitals and sanatoriums find greater Dec. 8th to discuss procedure. It was decided that in obtaining recruits to their nursing staffs difficulty the first duty of the Commission was to obtain than any other type of hospital, questionnaires evidence whether an absolute shortage of candi- were sent to 124 such institutions throughdates for nursing the sick in institutions really out the country. These institutions were selected exists, or whether the shortage is only that of candi- at random, by pricking four institutions on every dates with educational qualifications and personal page of the Ministry of Health Memorandum 122 D/T. qualities which are likely to enable them to make Altogether 1257 of these questionnaires were sent satisfactory nurses. It was also considered necessary out, distributed according to the tables set out below. to ascertain : (1) Whether the shortage relates to candidates for training, or to trained nurses for staff 1 Complete training schools are those which have satisfied the appointments, or to both these categories. (2) Whether General Nursing Council that medical, surgical, gynæcological, the shortage is felt in hospitals approved as training and children’s diseases services are provided. At least one medical officer must be kept, the period of training schools by the General Nursing Councils of England resident must be not less than three years, and the ratio of medical to and Wales, Scotland and Ireland, as well as by those surgical beds must not exceed 2 : 1, or be less than 1 : 2. Affiliated Hospitals are not considered sufficiently large to not so approved. .

General, culosis for

I

’

3. It

that a questionnaire should be and should be sent to the responsible prepared authorities of all hospitals approved as training centres and to a number of other hospitals not so approved. At the same time, it was agreed to ask I other questions, the answers to which might at least I provide a basis for discussion, and at best show clearly what conditions can be correlated with a waiting-list and what with a pronounced shortage. It was realised that among hospitals giving good training, the variables influencing the position might include the geographical position of the hospital, its accessibility, its prestige, its size, and the amenities offered to nurses undergoing training, as well as many other factors. Among hospitals not approved as was

agreed

equally

5609

give a complete training, but may be affiliated to a complete training school. Four years’ training is here compulsory, two years being spent in the affiliated hospital, at the end of which the preliminary state examination is taken. Having passed this examination, the probationer goes to the larger hospital

for two years. Associated Hospitals.—(1) Hospitals deficient in one branch of training may, in order to supply that branch, associate themselves with another hospital which must have a resident medical officer. The combined period of training must extend over three and a half years. (2) A hospital for men only may associate itself in this way with a hospital for women only and one for children only, when the course may extend over four years. Reciprocal Hosp itals.—Reciprocity between special and general hospitals involves two years in an approved special hospital and two years in a general hospital. Training in the special hospital must include the subjects of the preliminary State examination. 2

These lists may be incomplete. Hospitals in counties with beginning with C, S, K. or M which have not received questionnaires are asked to communicate immediately with the Hon. Sec. at THE LANCET Office.

names

I

452 Of these, Tables A and B include all the hospitals approved as training schools by the General Nursing Councils of England and Wales, Scotland and Ireland, while Table C includes only the sample of hospitals not approved as training schools to which questionnaires have been sent.

Hospitals

to which

Questionnaires

TABLE A.-GENERAL REGISTERS HOSPITALS

APPROVED

AS

COMPLETE

were

Sent.

(G.N.C.).

TRAINING

SCHOOLS.

the material in report to make preliminary It decided returned to Feb. l5th. up groups certain to to ask him to begin with the analysis of the on

a

was

answers

questionnaire : (1) from the general hospitals approved by the General Nursing Council of England and Wales, and (2) from general and special hospitals not so approved. The analysis of the answers to questions 13-36 and of the returns from the other groups is proceeding as fast as possible. 8. Dr. Bradford Hill’s preliminary report was submitted at the third meeting of the Commission held on Monday, Feb. 23rd, and it was then decided to publish it as an interim report of the Commission in order that its implications might be available for the large number of associations and individuals who questions

1-12-the shorter

have manifested interest in the progress of the work of the Commission. Dr. Bradford Hill’s reports on the returns from other groups will be published

shortly. TABLE B.——5PECIAL HOSPITALS

APPROVED

REGISTERS

FOR

SPECIAL

TRAINING.

Questionnaire. following covering letter was addressed by The

(G.N.C.). 9. The

the Chairman of the Commission to the Chairman of the Governing Body of each hospital : Offices of THE LANCET, 7, Adam-street, W.C.2.

I THE LANCET COMMISSION

ON

NURSING.

January, 1931.

SiR,-The members of this Commission TABLE C.-HOSPITALS NOT APPROVED AS TRAINING QUESTIONNAIRES HAVE BEEN SENT.

SCHOOLS TO WHICH

6. It was, however, realised that statistical evidence cannot alone provide a solution of the problem, especially since the quantity of the applicants may suffice and yet the quality may be poor. Ample space on the questionnaire for was, therefore, the the shortage, and this on reasons for opinions section has indeed supplied most helpful material. It was noticeable that where the presence of a waiting-list was reported, the responsible officer who filled up the form (the matron or, in some cases, the medical superintendent) nearly always suggested reasons for the shortage which was understood to exist in other hospitals less favoured. Although individual hospitals report no shortage, nowhere has serious doubt been expressed of the fact that a shortage exists. 7. A second meeting of the Commission was held on Jan. 19th, 1931, when it was reported that already It was then some 250 replies had been received. decided to subject the whole of the material to statistical analysis. Prof. Major Greenwood, F.R.S., Director of the Department of Epidemiology and Vital Statistics at the London School of Hygiene and Tropical Medicine, kindly agreed that this work might be done for the Commission in his Department under the supervision of Mr. A. Bradford Hill, D.Sc. In order that the Commission should have an early indication of the directions in which their further inquiries could usefully be extended, Dr. Bradford Hill was asked

provided

are

anxious to

explore the extent of the shortage of applicants for hospital vacancies, both as regards probationers and staff nurses, One object of the in different parts of the country. Commission is to suggest methods of recruiting the most suitable candidates. At the same time it is desirable to ascertain the general conditions of service, and also in the case of probationers the nature and extent of training afforded. In order that our inquiry may be based upon accurate information, we wish to appeal for the help of hospital authorities. A questionnaire is enclosed, and we should be obliged if you would be so good as to invite the Matron or some other responsible person to fill up the form, and perhaps you will return it to us as soon as possible. While my colleagues are reluctant to increase the burdens of officials whom we know to be seriously pressed for leisure, we none the less hope that we may receive their friendly collaboration, in view of the far-reaching importance of the subject. I am. Sir. vours faithfullv. CRAWFORD AND BALCARRES, Chairman. ISSUED BY THE LANCET COMMISSION

QUESTIONNAIRE ON

NURSING, JANUARY, 1931.

A, Sisters B, Staff Nurses ; and C, Probationers ? 2. What number of A, B, and C have you working at the present time ? 3. Have you a waiting list for vacancies (A, B, and C) 4. If not, do your advertisements for A, B, and C 1. What is your full establishment of

usually bring

sufficient

replies

from suitable

candidates ? 5. At what age do you admit

6.

7.

8.

probationers ? What are the educational requirements for acceptance of a probationer (seventh standard, secondary education, school-leaving certificate, matriculation, etc.) ? May we have a copy of : (a) The rules sent to prospective candidates if not identical with (b)z (b) The rules handed to nurses ? Is a separate bedroom provided for each

probationer ?

453 9. Have you found it necessary to employ " temIf so, how many are working porary nurses " in the hospital at the present time ?‘ 10. How many domestic workers

maids,

or daily workers) duty only ?

are

(orderlies,

employed

on

ward ward

11. What is the average number of beds occupied per night over a year ? 12. Please state briefly below what you believe to be the reasons for any shortage of B (staff nurses) and C (probationers), and suggest measures which might relieve it.

13.

14.

May we have a copy of the training school prospectus How many probationers did you admit in : 1928, 1929, and 1930 ?

15. How many candidates last year° 16. Of the

passed

Are

night

36. Lectures : Time of time ?

day ?

probationer.

nurses

relieved at

night

for meals ?

In off

duty

In

duty

Much evidence has already been submitted to the by those interested in its work from various points of view. Any organisation or individual wishing to provide evidence for the Commission to consider, or to make proposals relating to the improvement of conditions of service of the nursing profession, is asked to communicate before March 15th with the hon. secretary at THE LANCET Offices, 7, Adam-street, Adelphi, London, W.C.

Commission

Questionnaires still outstanding

are

urgently

needed for the completion of the analysis. Their immediate return would greatly facilitate the work of the Commission.

the final S.R.1.

who failed to complete their training in 1928, 1929, and 1930, how many left-during their first year, during their second year, and during their third year-as a result of : (a) illhealth ; (b) marriage ; (c) failure to pass examinations ; (d) sickness at home ; and (e) other causes 17. What is the length of the training coursez? 18. Do probationers have to undertake to work for the hospital for a year after completion of

FIRST INTERIM REPORT.

nurses

STATISTICAL ANALYSIS OF THE SHORTER

QUESTIONNAIRE [QUESTIONS 1 TO 12]

ISSUED TO HOSPITALS BY THE LANCET COMMISSION ON NURSING.

BY A. BRADFORD HILL, PH.D., D.SC.

training? (if any) fee or deposit has by probationers on starting training ?‘?

19. How much

to be

paid

20. How much

Introduction. For the purposes of this preliminary examination there have been chosen for comparison two main groups of hospitals :(1) Those approved by the General Nursing Council for complete training in General Nursing ; and

are probationers and trained staff paid : (a) first year ; (b) second year ; (c) third year; (d) staff nurses, if different from third year nurses ; (e) sisters? 21. Are you affiliated to a superannuation scheme ? (2) Hospitals not approved as training centres. If so, is membership compulsory? These two main groups havebeen further sub22. Is there a separate uniform and laundry allowance divided as follows :And if so, how much (a) Laundry allowance ; (1) Approved for Complete Training in General (b) uniform allowance. Nursing : 23. Are outdoor uniforms compulsory ? If so, are (a) London Voluntary. they provided ? (b) Provincial Voluntary. 24. Have you any facilities for exercise and recreation? (c) London and Provincial Municipal. 25. Are common-rooms provided ? (2) Hospitals not approved : 26. Are men guests admitted ? (a) General hospitals. 27. Is smoking permitted in any part of the nurses’ (b) Special hospitals (e.g., orthopaedic, ear,

home?

28. Have the senior

nose, and nurses a

latch-key

?°?

The latter group is

throat).

a sample of those throughout and Wales selected in the manner described pass ? (Par. 5) in the statement by the Commission. The statistics throughout relate only to hospitals situated 30. Is attendance at meals compulsory even when and Wales. Returns have been secured in England hours meal-times are adjacent to off-duty also from hospitals in Scotland and Ireland, but these, 31. What are the duty hours of nurses’ By day ; together with the returns from special hospitals by night. approved as training centres (for the State examina32. What are hours off for meals ? Breakfast, early tions for Sick Children’s nurses, Fever nurses, and lunch, lunch, tea, supper. Mental nurses), have been held over for later analysis. 33. Off-duty times and holidays : (1) Daily ; (2) The present study does not include all the hospitals of the particular type to which the questionnaire fortnightly ; (3) weekly ; (4) yearly. was sent. Not all the returns are yet to hand, but 34. Notice in advance of off-duty times and holidays : in each case the analysis includes at least half of Hours off ; day off ; annual holiday. those from which it is hoped to secure information 35. Night duty : Stretch of night duty ; nights per (vide Table 1.). By a preliminary analysis it was month off duty for night sister, staff nurse, hoped to secure some indications of the factors to

29. What time must

nurses

be back without

a

late

England