- Email: [email protected]
NURSING PROBLEMS IN THE PROVINCES
86 done. But a few hours’ sleep, well laced with dreams of first stages lasting a fortnight, found me at 7 A.M. refreshed and ready to face facts. As usual, however, this frame of mind did not last long. At 7.30 I got a note from a lady with a rash who wanted a visit. At 7.4:5 my post informed me that two of my maternity cases were Rh-negative, a skin patient needed special treatment, and half a dozen X-ray reports required filing. At 8 my maternity case was getting on nicely, and would I come at once. From then on events moved fast. Baby and placenta were delivered and expressed by 9.10, breakfast eaten by 9.20, packing finished by 9.30, and I was in the train by 9.45. At the first station along the line the face of my Bell’s palsy peered at me through the window, but her smile of recognition was reassuringly normal. Opposite me on its mother’s lap sat a nine-month-old baby. It wasn’t regurgitating its feed ; it didn’t go into a convulsion ; there was no sign of a rash ; it didn’t even appear to have a cough. I hadn’t seen such a phenomenon for almost a year. Then at last I realised I really was on holiday among healthy happy people who had more important things to do than sit in a doctor’s waitingroom. Somehow I had forgotten such folk existed.
packing wasn’t
*
*
*
*
When I am on holiday in the country I find I soon get to recognise the doctor on his rounds. Everyone knows his car, and everyone knows, or soon knows, the reason for his presence in hamlet or village-a baby here, an accident there, old Mrs. Brown rather poorly, old Grocer Jones dying. In holiday mood, with walkingstick, thick-soled shoes, and somewhat bedraggled clothes, I find it difficult to believe that my own normal work is of the same kind. But when I return to duty, fortified by the grand walks and fresh air, I always have in mind, as one of its memories, a picture of a colleague doing a fine job, often under great difficulties. Sometimes then I feel a little envious of the country doctor’s prestige and of the affection in which he is held, but that feeling never lasts through the cycle of the year. When winter comes, the moorland tracks and lonely farms, so beautiful in my holiday scene, become strangely sinister ; and then I am truly glad that fate has landed me in an urban practice, when on a blustering night of wind and rain I am called to see someone " just down the street." *
*
to
the Editor
CORTISONE IN BELL’S PALSY
SIR,—Your annotation of June 13 suggests that the using cortisone early in 5 cases seen in the neurology department here might be of interest.
results of
Treatment consisted of 100 mg. cortisone daily by mouth, combined with 2 g. KC1 and low salt and fluid The dosage, results, and clinical detail are intake. shown in the accompanying table. 4 patients were seen DATA ON
5 CASES
OF
BELL’S
PALSY TREATED WITH CORTISONE
*
It is difficult to imagine just how the Elizabethans lived, talked, and ate, and still more difficult to reproduce their way of doing these things. But last week, at its sports ground down in Surrey, St. Thomas’s Hospital gallantly held an Elizabethan banquet to celebrate the 400th anniversary of its re-foundation by King Edward VI on June 26, 1553. To work up the proper atmosphere, earlier in the day, at the Stoke D’Abernon Coronation Fair, some students had re-enacted a ride made by Queen Elizabeth I to knight a local worthy. Some thirty horsernen and horsewomen (with appropriate sidesaddles) made a colourful picture as they rode on to the village green after the three-mile ride from Cobham to Stoke, and the Queen duly knighted Sir Thomas Vincent on the sward. With the lovely setting of the 12th-century church as back-cloth for the banquet, the menu included swan, peacock, lobster, and badger, and pigs were ceremonially roasted on spits nearby. Some 250 guests partook of these bygone delicacies, some critically, some admiringly. To all, the occasion was novel ; to most, it was enjoyable. A string orchestra discoursed sweet music, and Elizabethan ghosts, despite the flood-lighting, flitted in the shadows of the trees. After the toasts the night ended, appropriately enough, with dancing on the green. *
Letters
*
" England indeed stand in great peril." " In a trice the petals were stripped from the English rose." England once more were heading for a trackless desert." " England, it seemed, were nearly at the end of their tether." " Now the door was ajar and England put their shoulder to it manfully." "Having pressed home the dagger, he turned it mercilessly as England lay mortally wounded...." Had you not read it would you e’er have guessed That thus The Tines wrote of the Second Test ?
*
Reckoned from start of treatment.
within forty-eight hours of the clinical onset of palsy, and 1 within four days. In all the palsy was already complete or almost complete. The behaviour of: Bell’s palsy soon after onset is notoriously difficult to predict, and there is nothing in the results of these 5 cases which could be regarded as unequivocal evidence that cortisone had affected the natural history of the lesion. In more was there any dramatic recovery. Many might consider, however, that for 3 out of 5 cases with substantially complete early palsy to show the beginning of recovery within fourteen days, thus clearly indicating that recovery by regeneration was not necessary, is unusual in this condition. The evidence is only suggestive. Analysis of a large number of cases so treated would probably provide an answer ; but the
drug is expensive and scarce at present, proportion of cases likely to have much permanent disability-at any rate in the younger age-groups-is
and the
very small. Department
of Neurology, Neurology, Radcliffe Infirmary, Oxford.
M. WHITTY. C W. C. W. M. WHITTY. Oxford. NURSING PROBLEMS IN THE PROVINCES
SIR,—May I question some of the points raised in your leading article of June 27 ?‘? You have misunderstood the reasons behind my assumption that the raising of the age of entry from 17 to 18 would mean a permanent reduction in the number of students working in hospitals. It may well be that the majority of girls not accepted at 17 will survive the next six months and enter at 18 ; but, just as raising the school-leaving age reduces the man-power available for industry, so the raising of the age of entry for nurse training must reduce the total strength of nurses in training. If, in the past, 6000 girls have entered each year at the age of 171/2, and subsequently completed their training, then the hospitals will lose 6000 periods of six months-the equivalent of 3000 staff ; or to put it another way, these 6000 girls have given three and a half years’ service during their training, and will, in future, give only three years’ service, thus representing a permanent reduction in the total nursing strength. I do not quite understand your suggestion that the educational standard will probably be that reached by the ordinary girl leaving a secondary grammar or modern school at the age of 15 ; the only girls who do not leave such schools at 15 or over are those who attend technical
87
secretar:. il schools. Moreover, the (General Nursing Council have laid down their policy precisely and publicly ; or
they have agreed that the educational requirements shall be the General Certificate of Education at. ordinary level in two subjects, and, in addition, " aCertificate from the Headmaster or Headmistress that the candidate has satisfactorily completed a five-year grammar school course, during which time she has studied and reached at least five subjects." a satisfactory standard in Ifbis policy is carried out it must lead to an alarming reduction in the number of entrants for nurse
training. Your picture of the staffing structure of the future -makes gloomy reading, because it confirms what I had thought to be the policy behind the recent developments If you envisage Iiospitals referred to in my paper. turning over from the training of State-registered nurses to the training of assistant nurses, you must be reconciled to a large reduction in the number of State-registered nurses. Even with the present number of full training schools, and a high level of recruitment, almost every hospital finds it difficult to obtain sufficient trained State-registered nurses to provide the minimum nucleus of trained staff in wards and departments. It is hard to, imagine what the position will be if there is a substantial reduction in the number of State-registered nurses, and it is most unlikely that the nursing profession will be so attractive to girls if a substantial proportion can be offered only training as assistant nurses with no possibisity of promotion or advancement. No-one would object to orderly progress in the standard of training and status of nurses, but steps should not be taken unilaterally, without regard to their effect on the hospital service and the communitv ,as a whole. It will be a sad day for provincial hospitals if ward staffs consist of one or two trained nurses, and such assistant nurses and pupil assistant nurses as can be found, with most of the bedside nursing undertaken by ward orderlies. It is not, as you imply, merely a question of loss of face, or of financial loss to the matrons ; and indeed this inference is rather unworthy, since matrons as a whole are far more concerned with the status and wellbeing of their hospitals than they are with their own remuneration. A general hospital compelled to change over from training State-registered nurses to training assistant nurses would be in an appalling position, since, apart from the loss of all its student nurses, and their highly conjectural replacement by pupil assistant nurses, they would be entirely dependent on recruitment from other hospitals for their trained staff : the great majority of trained nurses seeking other posts, would prefer to go to a hospital which is a recognised training school for State-registered nurses rather than to an assistant-
non-teaching
nurse
training-school.
Let those concerned with the evolution of high policy consider every possible means of improving the standard and status of the nursing profession, but let us not blind ourselves to the realities of the situation and to the dangers inherent in the present trend of events. The notion of the nursing team, to which you make passing reference, is all very well as an ideal ; but to carry it into effect at the moment would mean closing half the hospital beds in the country. R. E. LINGARD Luton.
Secretary, Luton and Hitchin Group Hospital Management Committee.
We are informed that the General Nursing Council already alive to the criticism raised by Mr. Lingard in his second paragraph, and that that is why they are reconsidering the educational requirements for ,entrants to training for the State register. Their final policy, we understand, will be published later.-ED. L. are
SIR, —Your editorial is timely and important. Although there are hospitals in London and in the main teaching centres that can afford to pick and choose between the applicants for training, there is undoubtedly a sorious shortage at the majority of our hospitals throughout the country. We have now two separate courses of training-the one for the student nurse who becomes the Stateregistered nurse and the other for the assistant nurse who will not be State-registered but who will be put on to the Roll of Assistant Nurses. The assistant nurse is debarred from advancement to higher grades of nursing and administrative posts unless she returns to the startingpoint and takes up the training of the student nurse, receiving as compensation a rebate of six months. The two training courses are separate, and indeed the association of the members of the two groups in the same hospital and ward is looked upon as undesirable. Your cheerful and hopeful picture of the nursing team all working happily together is therefore of doubtful accuracy. Added to this it is clear that those who choose to be trained as assistant nurses will in the end be called upon to nurse the aged and chronic sick, which holds out little of the glory and excitement associated with general and special nursing in our larger hospitals. The further possibility that basic nursing will have to be carried out by nursing orderlies is not an entirely comforting thought, notwithstanding the excellent work this latter group have been doing. It is therefore not unlikely that the assistant nurse will develop feelings of inferiority, and if this should be so it would indeed be a sad day for
nursing. that the recommendations of the of be reconsidered at the highest 1948 Working Party level, the ’main recommendation being that there should be one training course of two years so as to quickly ensure a number of basic nurses sufficient to meet the present shortage. At the end of the two years those basic nurses who wish to do so, and are judged to be suitably equipped mentally, would be able to proceed to the higher grades of nursing, which can become as academic and scientific as our Royal College of Nursing thinks fit. We shall then have practical nurses who will be available for all departments of ordinary nursing care, and none will be debarred from proceeding to higher administrative posts if they prove their worth and ability. At the same time any feeling of inferiority will disappear. There are, I think, many who feel that the present syllabus, let alone the new one, is overloaded with academic lectures and tutorials, and that the inordinate desire of the Royal College of Nursing to upgrade the nurse’s training is creating much the same position in nursing as in medicine, where we are producing large numbers of would-be specialists and consultants who view general practice as something in the nature of the last ditch. Both in nursing and in doctoring there must be a wide range of ability, experience, and technique. Nevertheless for the mass of sick people we must have large numbers of practical basic nurses and family doctors. The argument that a single shorter and simpler course for all nurses at the start would fail to attract the best nursing material is I think without substance. A good nurse is not made by large numbers of lectures and a training in the higher flights of medicine and surgery and by turning her into a 75% doctor. There is only a single entrance and a single training for the doctor, and those who look forward to a specialist and consultant career are not put off at the start by training alongside those who aim at general practice. Those who finally become specialists and consultants do so by proving their worth in keen competition and hard training. WILFRED VINING. Leeds.
I therefore
suggest
packing wasn’t
*
*
*
*
When I am on holiday in the country I find I soon get to recognise the doctor on his rounds. Everyone knows his car, and everyone knows, or soon knows, the reason for his presence in hamlet or village-a baby here, an accident there, old Mrs. Brown rather poorly, old Grocer Jones dying. In holiday mood, with walkingstick, thick-soled shoes, and somewhat bedraggled clothes, I find it difficult to believe that my own normal work is of the same kind. But when I return to duty, fortified by the grand walks and fresh air, I always have in mind, as one of its memories, a picture of a colleague doing a fine job, often under great difficulties. Sometimes then I feel a little envious of the country doctor’s prestige and of the affection in which he is held, but that feeling never lasts through the cycle of the year. When winter comes, the moorland tracks and lonely farms, so beautiful in my holiday scene, become strangely sinister ; and then I am truly glad that fate has landed me in an urban practice, when on a blustering night of wind and rain I am called to see someone " just down the street." *
*
to
the Editor
CORTISONE IN BELL’S PALSY
SIR,—Your annotation of June 13 suggests that the using cortisone early in 5 cases seen in the neurology department here might be of interest.
results of
Treatment consisted of 100 mg. cortisone daily by mouth, combined with 2 g. KC1 and low salt and fluid The dosage, results, and clinical detail are intake. shown in the accompanying table. 4 patients were seen DATA ON
5 CASES
OF
BELL’S
PALSY TREATED WITH CORTISONE
*
It is difficult to imagine just how the Elizabethans lived, talked, and ate, and still more difficult to reproduce their way of doing these things. But last week, at its sports ground down in Surrey, St. Thomas’s Hospital gallantly held an Elizabethan banquet to celebrate the 400th anniversary of its re-foundation by King Edward VI on June 26, 1553. To work up the proper atmosphere, earlier in the day, at the Stoke D’Abernon Coronation Fair, some students had re-enacted a ride made by Queen Elizabeth I to knight a local worthy. Some thirty horsernen and horsewomen (with appropriate sidesaddles) made a colourful picture as they rode on to the village green after the three-mile ride from Cobham to Stoke, and the Queen duly knighted Sir Thomas Vincent on the sward. With the lovely setting of the 12th-century church as back-cloth for the banquet, the menu included swan, peacock, lobster, and badger, and pigs were ceremonially roasted on spits nearby. Some 250 guests partook of these bygone delicacies, some critically, some admiringly. To all, the occasion was novel ; to most, it was enjoyable. A string orchestra discoursed sweet music, and Elizabethan ghosts, despite the flood-lighting, flitted in the shadows of the trees. After the toasts the night ended, appropriately enough, with dancing on the green. *
Letters
*
" England indeed stand in great peril." " In a trice the petals were stripped from the English rose." England once more were heading for a trackless desert." " England, it seemed, were nearly at the end of their tether." " Now the door was ajar and England put their shoulder to it manfully." "Having pressed home the dagger, he turned it mercilessly as England lay mortally wounded...." Had you not read it would you e’er have guessed That thus The Tines wrote of the Second Test ?
*
Reckoned from start of treatment.
within forty-eight hours of the clinical onset of palsy, and 1 within four days. In all the palsy was already complete or almost complete. The behaviour of: Bell’s palsy soon after onset is notoriously difficult to predict, and there is nothing in the results of these 5 cases which could be regarded as unequivocal evidence that cortisone had affected the natural history of the lesion. In more was there any dramatic recovery. Many might consider, however, that for 3 out of 5 cases with substantially complete early palsy to show the beginning of recovery within fourteen days, thus clearly indicating that recovery by regeneration was not necessary, is unusual in this condition. The evidence is only suggestive. Analysis of a large number of cases so treated would probably provide an answer ; but the
drug is expensive and scarce at present, proportion of cases likely to have much permanent disability-at any rate in the younger age-groups-is
and the
very small. Department
of Neurology, Neurology, Radcliffe Infirmary, Oxford.
M. WHITTY. C W. C. W. M. WHITTY. Oxford. NURSING PROBLEMS IN THE PROVINCES
SIR,—May I question some of the points raised in your leading article of June 27 ?‘? You have misunderstood the reasons behind my assumption that the raising of the age of entry from 17 to 18 would mean a permanent reduction in the number of students working in hospitals. It may well be that the majority of girls not accepted at 17 will survive the next six months and enter at 18 ; but, just as raising the school-leaving age reduces the man-power available for industry, so the raising of the age of entry for nurse training must reduce the total strength of nurses in training. If, in the past, 6000 girls have entered each year at the age of 171/2, and subsequently completed their training, then the hospitals will lose 6000 periods of six months-the equivalent of 3000 staff ; or to put it another way, these 6000 girls have given three and a half years’ service during their training, and will, in future, give only three years’ service, thus representing a permanent reduction in the total nursing strength. I do not quite understand your suggestion that the educational standard will probably be that reached by the ordinary girl leaving a secondary grammar or modern school at the age of 15 ; the only girls who do not leave such schools at 15 or over are those who attend technical
87
secretar:. il schools. Moreover, the (General Nursing Council have laid down their policy precisely and publicly ; or
they have agreed that the educational requirements shall be the General Certificate of Education at. ordinary level in two subjects, and, in addition, " aCertificate from the Headmaster or Headmistress that the candidate has satisfactorily completed a five-year grammar school course, during which time she has studied and reached at least five subjects." a satisfactory standard in Ifbis policy is carried out it must lead to an alarming reduction in the number of entrants for nurse
training. Your picture of the staffing structure of the future -makes gloomy reading, because it confirms what I had thought to be the policy behind the recent developments If you envisage Iiospitals referred to in my paper. turning over from the training of State-registered nurses to the training of assistant nurses, you must be reconciled to a large reduction in the number of State-registered nurses. Even with the present number of full training schools, and a high level of recruitment, almost every hospital finds it difficult to obtain sufficient trained State-registered nurses to provide the minimum nucleus of trained staff in wards and departments. It is hard to, imagine what the position will be if there is a substantial reduction in the number of State-registered nurses, and it is most unlikely that the nursing profession will be so attractive to girls if a substantial proportion can be offered only training as assistant nurses with no possibisity of promotion or advancement. No-one would object to orderly progress in the standard of training and status of nurses, but steps should not be taken unilaterally, without regard to their effect on the hospital service and the communitv ,as a whole. It will be a sad day for provincial hospitals if ward staffs consist of one or two trained nurses, and such assistant nurses and pupil assistant nurses as can be found, with most of the bedside nursing undertaken by ward orderlies. It is not, as you imply, merely a question of loss of face, or of financial loss to the matrons ; and indeed this inference is rather unworthy, since matrons as a whole are far more concerned with the status and wellbeing of their hospitals than they are with their own remuneration. A general hospital compelled to change over from training State-registered nurses to training assistant nurses would be in an appalling position, since, apart from the loss of all its student nurses, and their highly conjectural replacement by pupil assistant nurses, they would be entirely dependent on recruitment from other hospitals for their trained staff : the great majority of trained nurses seeking other posts, would prefer to go to a hospital which is a recognised training school for State-registered nurses rather than to an assistant-
non-teaching
nurse
training-school.
Let those concerned with the evolution of high policy consider every possible means of improving the standard and status of the nursing profession, but let us not blind ourselves to the realities of the situation and to the dangers inherent in the present trend of events. The notion of the nursing team, to which you make passing reference, is all very well as an ideal ; but to carry it into effect at the moment would mean closing half the hospital beds in the country. R. E. LINGARD Luton.
Secretary, Luton and Hitchin Group Hospital Management Committee.
We are informed that the General Nursing Council already alive to the criticism raised by Mr. Lingard in his second paragraph, and that that is why they are reconsidering the educational requirements for ,entrants to training for the State register. Their final policy, we understand, will be published later.-ED. L. are
SIR, —Your editorial is timely and important. Although there are hospitals in London and in the main teaching centres that can afford to pick and choose between the applicants for training, there is undoubtedly a sorious shortage at the majority of our hospitals throughout the country. We have now two separate courses of training-the one for the student nurse who becomes the Stateregistered nurse and the other for the assistant nurse who will not be State-registered but who will be put on to the Roll of Assistant Nurses. The assistant nurse is debarred from advancement to higher grades of nursing and administrative posts unless she returns to the startingpoint and takes up the training of the student nurse, receiving as compensation a rebate of six months. The two training courses are separate, and indeed the association of the members of the two groups in the same hospital and ward is looked upon as undesirable. Your cheerful and hopeful picture of the nursing team all working happily together is therefore of doubtful accuracy. Added to this it is clear that those who choose to be trained as assistant nurses will in the end be called upon to nurse the aged and chronic sick, which holds out little of the glory and excitement associated with general and special nursing in our larger hospitals. The further possibility that basic nursing will have to be carried out by nursing orderlies is not an entirely comforting thought, notwithstanding the excellent work this latter group have been doing. It is therefore not unlikely that the assistant nurse will develop feelings of inferiority, and if this should be so it would indeed be a sad day for
nursing. that the recommendations of the of be reconsidered at the highest 1948 Working Party level, the ’main recommendation being that there should be one training course of two years so as to quickly ensure a number of basic nurses sufficient to meet the present shortage. At the end of the two years those basic nurses who wish to do so, and are judged to be suitably equipped mentally, would be able to proceed to the higher grades of nursing, which can become as academic and scientific as our Royal College of Nursing thinks fit. We shall then have practical nurses who will be available for all departments of ordinary nursing care, and none will be debarred from proceeding to higher administrative posts if they prove their worth and ability. At the same time any feeling of inferiority will disappear. There are, I think, many who feel that the present syllabus, let alone the new one, is overloaded with academic lectures and tutorials, and that the inordinate desire of the Royal College of Nursing to upgrade the nurse’s training is creating much the same position in nursing as in medicine, where we are producing large numbers of would-be specialists and consultants who view general practice as something in the nature of the last ditch. Both in nursing and in doctoring there must be a wide range of ability, experience, and technique. Nevertheless for the mass of sick people we must have large numbers of practical basic nurses and family doctors. The argument that a single shorter and simpler course for all nurses at the start would fail to attract the best nursing material is I think without substance. A good nurse is not made by large numbers of lectures and a training in the higher flights of medicine and surgery and by turning her into a 75% doctor. There is only a single entrance and a single training for the doctor, and those who look forward to a specialist and consultant career are not put off at the start by training alongside those who aim at general practice. Those who finally become specialists and consultants do so by proving their worth in keen competition and hard training. WILFRED VINING. Leeds.
I therefore
suggest