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Special Supplement. THE LANCET COMMISSION ON NURSING SECOND INTERIM REPORT
Special Supplement. THE LANCET COMMISSION ON
NURSING SECOND INTERIM REPORT The Commission wish to record their gratitude to Dr. Hill for the arduous task he has accomplished with so much skill, and to Prof. Major Greenwood for kindly agreeing that the work should be done in the Department of Epidemiology and Vital Statistics of the London School of Hygiene and
THE LANCET Commission on Nursing was 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 attractive to women suitable for this necessary work. The members of the Commission are :-
Tropical Medicine.
The Commission are now engaged in considering the statistical evidence in connexion with the evidence The Earl of CRAWFORD and BALCARRES, P.C., K.T., which has been put before them by various organisaF.R.S. (Chairman). tions and individuals. Prof. HENRY CLAY, M.A., D.Se., late Professor of In order to provide a convenient index for readers, Social Economics in the of Manchester. the questionnaire issued is set out below, the relevant Miss R. E. DARBYSHIRE, R.R.C., Matron, University paragraphs and tables in Dr. Bradford Hill’s final report being appended to each question. College Hospital. Miss L. CLARK, M.B.E., R.R.C., Matron, Whipps QUESTIONNAIRE ISSUED BY THE LANCET COMMISSION Cross Hospital. ON NURSING, JANUARY, 1931. Dr. ROBERT HUTCHISON, F.R.C.P., Physician to the 1. What is your full establishment of A, Sisters ; London Hospital and to the Hospital for Sick Children, B, Staff Nurses ; and C, Probationers1 (Para. 6 ; Great Ormond-street. Table II.) Prof. F. R. FRASER, M.D., F.R.C.P., Professor of 2. What number of A, B, and C have you working Medicine in the University of London, Physician to at the present time ?(Paras. 6, 7, 8, 19 ; Tables St. Bartholomew’s Hospital. II., III., X.) Mr. A. LISTER HARRISON, J.P., Chairman, Com3. Have you a waiting list for vacancies (A, B, and mittee of Management, Metropolitan Hospital. C) (Para. 9 ; Table IV.) Miss M. D. BROCK, O.B.E., M.A., Litt.D., Head- j If 4. not, do your advertisements for A, B, and C mistress, the Mary Datchelor Girls’ School. usually bring sufficient replies from suitable Mrs. OLIVER STRACHEY, Chairman, Employments candidates ? (Paras. 9, 10, 11, 12, 13, 14 ; Committee, London Society for Women’s Service. Table IV.) Miss EDITH THOMPSON, C.B.E., Member of Council, 5. At what age do you admit probationers ? (Para. Bedford College, University of London. 15 ; Table VI.) Sir SQUIRE SPRIGGE, M.D., F.R.C.P., the Editor of 6. What are the educational requirements for THE LANCET, with Dr. M. H. KETTLE, an assistant acceptance of a probationer (seventh standard,
University
,
I
editor,
honorary secretary. In order to ascertain the degree and the nature of the shortage, and the conditions of training and service offered, the Commission decided to send a questionnaire to the responsible authorities of all hospitals approved as training centres by the General Nursing Councils of England and Wales, Scotland, and Ireland, and to a number of other hospitals not so approved. Altogether 1251 questionnaires were as
7.
8. 9.
hospitals
sent out, of which 1031 were addressed to in England and Wales, 118 to hospitals in Scotland, and 102 to hospitals in Ireland. The first Interim Report of the Commission was published in THE LANCET of Feb. 28th, 1931, when the distribution of the questionnaire to various groups of hospitals was described. The principal feature of the First Interim Report, however, was a preliminary analysis, by Mr. A. Bradford Hill, D.Sc., of the returns received before Feb. 15th from hospitals in certain groups. That preliminary analysis is now rendered obsolete by Dr. Hill’s Final Report on the material submitted to him, which is set out below.
10.
11.
12.
secondary education, school-leaving certificate, matriculation, etc.)? (Para. 16 ; Table VII.) May we have a copy of : (a) The rules sent to prospective candidates if not identical with (b)? (b) The rules handed to nurses ? Is a separate bedroom provided for each probationer ? (Para. 17 ; Table VIII.) Have you found it necessary to employ " temporary nurses "? If so, how many are working in the hospital at the present time ? (Para. 14 ; Table V.) How many domestic workers (orderlies, ward maids, or daily workers) are employed on ward duty only? (Para. 18 ; Table IX.) What is the average number of beds occupied per night over a year (Paras. 18, 19 ; Tables IX., X.) 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. (Paras. 20, 70, 71, 72, 73, 74, 75, 76.)
ii
13. 14. 15. 16.
May we have a copy of the training school prospectus ? How many probationers did you admit in : 1928, 1929, and 1930 ? (Para. 21 ; Tables XI., XIIA.) How many candidates passed the final S.R.N. last year ? (Para. 21 ; Tables XI., XIIA.) Of the nurses 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 ? (Paras. 21, 22 ; Tables XII., XIIA.) 17. What is the length of the training course? (Para. 23 ; Table XIII.) 18. Do probationers have to undertake to work for the hospital for a year after completion of training? (Para. 24 ; Table XIII.) 19. How much (if any) fee or deposit has to be paid
by probationers Table XIV.)
on
starting training
(Para. 25 ;
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 ? (Paras. 26, 27, 28, 29,
20. How much
Tables XV.,
30, 32 ; XIXA.)
XVI., XVII., XVIII., XIX.,
21. Are you affiliated to a superannuation scheme’? If so, is membership compulsory ? (Para. 33 ; Table XX.) 22. Is there a separate uniform and laundry allowance ? And if so, how much ? (a) Laundry allowance ; (b) uniform allowance. (Para. 31.) 23. Are outdoor uniforms compulsory ? If so, are
(Para. 31.)
they provided ?
24. Have you any facilities for exercise and recreation ? (Para. 34; Table XXI.) 25. Are common-rooms provided‘? (Para. 35 ; Table XXI.) 26. Are men guests admitted ? (Para. 36 ; Table XXI.) 27. Is smoking permitted in any part of the nurses’ home? (Para. 37 ; Table XXI.) 28. Have the senior nurses a latch-key ? (Para. 39 ;
Table
XXII.)
be back without a late Table XXII.) 30. Is attendance at meals compulsory even when meal-times are adjacent to off-duty hours ? (Para. 45 ; Table XXIV.) 31. What are the duty hours of nurses ? By day ; 29. What time must
pass ?
32.
33.
nurses
(Para. 38 ;
by night? (Paras. 46, 47, 52, 53, 54, 55 ; Tables XXV., XXVI., XXX.) What are hours off for meals ? Breakfast, early lunch, lunch, tea, supper. (Paras. 40, 41, 42, 43, 44, 45, 52 ; Tables XXIII., XXX.) Off-duty times and holidays : (1) Daily; (2) fortnightly; (3) weekly; (4) yearly. (Paras. 48, 49, 50, 51, 52; Tables XXVII., XXVIII.,
XXIX., XXX.) 34. Notice in advance of off-duty times and holidays : Hours off ; day off ; annual holiday. (Paras. 56, 57, 58, 59; Tables XXXI., XXXII.) 35. Night duty : Stretch of night duty ; nights per month off duty for night sister, staff nurse, probationer. Are night nurses relieved at night for meals ? (Paras. 60, 61, 62 ; Tables XXXIII.,
XXXIV.) 36. Lectures : Time of day’ ? In off duty ? In time’? (Paras. 63, 64 ; Table XXXV.)
duty
’
STATISTICAL
ANALYSIS OF THE
QUESTIONNAIRE ISSUED TO HOSPITALS BY "THE LANCET" COMMISSION ON NURSING.
FINAL REPORT SUBMITTED TO THE
COMMISSION. BY A. BRADFORD
HILL, PH.D., D.SC.
Introduction. 1. THE first interim report, published in THE LANCET of Feb. 28th, 1931, was confined to a statis. tical analysis of the replies received in answer to the first 12 questions of a long questionnaire which had been issued to 1251 hospitals by THE LANCET Commission on Nursing. That preliminary analysis has now been extended to cover, in addition, the further 24 questions which were put at the same time to all approved Training Schools1 among these 1251 hospitals. The earlier study was limited to a sample of the answers received from five groups of hospitals, viz. : Training Schools approved by the General Nursing Council for complete training,2 as represented by London Voluntary, Provincial Voluntary, and London and Provincial Municipal Hospitals, and Hospitals not approved as training schools, which were subdivided into General and Special hospitals. As well as extending the analysis to questions 13-36, the present report deals again with the answers to questions 1-12 received from five groups of hospitals dealt with in the first interim report, to which have been added further hospitals in the same categories. These are here set out, together with answers received from the seven other types of hospitals to which the questionnaire was also issued-namely, hospitals approved for partial training (Affiliated, Associated, Reciprocal),2 hospitals approved as training schools for supplementary registers (Children, Fever, Mental), and Tuberculosis hospitals ; this gives in all 12 groups (totalling 1031 hospitals), as shown in Table I., all these thousand hospitals (with the exception of certain tuberculosis hospitals) being situated in England and Wales. Questionnaires were also sent to 118 Scottish and 102 Irish hospitals within the same categories. The groups in these countries were in some cases exceedingly small (e.g., in Scotland there are only three, in Ireland only two children’s hospitals approved as training 1 Questions 18-36
were
put also to tuberculosis hospitals and
sanatoriums. 2
Complete training schools are those which have satisfied the General Nursing Council that medical, surgical, gynæcological, and children’s diseases services are provided. At least one resident medical officer must be kept, the period of training must be not less than three years, and the ratio of medical to surgical beds must not exceed 2 : 1, or be less than 1 : 2. Affiliated Hospitals are not considered sufficiently large to 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 Hospitals.—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.
NURSING SECOND INTERIM REPORT The Commission wish to record their gratitude to Dr. Hill for the arduous task he has accomplished with so much skill, and to Prof. Major Greenwood for kindly agreeing that the work should be done in the Department of Epidemiology and Vital Statistics of the London School of Hygiene and
THE LANCET Commission on Nursing was 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 attractive to women suitable for this necessary work. The members of the Commission are :-
Tropical Medicine.
The Commission are now engaged in considering the statistical evidence in connexion with the evidence The Earl of CRAWFORD and BALCARRES, P.C., K.T., which has been put before them by various organisaF.R.S. (Chairman). tions and individuals. Prof. HENRY CLAY, M.A., D.Se., late Professor of In order to provide a convenient index for readers, Social Economics in the of Manchester. the questionnaire issued is set out below, the relevant Miss R. E. DARBYSHIRE, R.R.C., Matron, University paragraphs and tables in Dr. Bradford Hill’s final report being appended to each question. College Hospital. Miss L. CLARK, M.B.E., R.R.C., Matron, Whipps QUESTIONNAIRE ISSUED BY THE LANCET COMMISSION Cross Hospital. ON NURSING, JANUARY, 1931. Dr. ROBERT HUTCHISON, F.R.C.P., Physician to the 1. What is your full establishment of A, Sisters ; London Hospital and to the Hospital for Sick Children, B, Staff Nurses ; and C, Probationers1 (Para. 6 ; Great Ormond-street. Table II.) Prof. F. R. FRASER, M.D., F.R.C.P., Professor of 2. What number of A, B, and C have you working Medicine in the University of London, Physician to at the present time ?(Paras. 6, 7, 8, 19 ; Tables St. Bartholomew’s Hospital. II., III., X.) Mr. A. LISTER HARRISON, J.P., Chairman, Com3. Have you a waiting list for vacancies (A, B, and mittee of Management, Metropolitan Hospital. C) (Para. 9 ; Table IV.) Miss M. D. BROCK, O.B.E., M.A., Litt.D., Head- j If 4. not, do your advertisements for A, B, and C mistress, the Mary Datchelor Girls’ School. usually bring sufficient replies from suitable Mrs. OLIVER STRACHEY, Chairman, Employments candidates ? (Paras. 9, 10, 11, 12, 13, 14 ; Committee, London Society for Women’s Service. Table IV.) Miss EDITH THOMPSON, C.B.E., Member of Council, 5. At what age do you admit probationers ? (Para. Bedford College, University of London. 15 ; Table VI.) Sir SQUIRE SPRIGGE, M.D., F.R.C.P., the Editor of 6. What are the educational requirements for THE LANCET, with Dr. M. H. KETTLE, an assistant acceptance of a probationer (seventh standard,
University
,
I
editor,
honorary secretary. In order to ascertain the degree and the nature of the shortage, and the conditions of training and service offered, the Commission decided to send a questionnaire to the responsible authorities of all hospitals approved as training centres by the General Nursing Councils of England and Wales, Scotland, and Ireland, and to a number of other hospitals not so approved. Altogether 1251 questionnaires were as
7.
8. 9.
hospitals
sent out, of which 1031 were addressed to in England and Wales, 118 to hospitals in Scotland, and 102 to hospitals in Ireland. The first Interim Report of the Commission was published in THE LANCET of Feb. 28th, 1931, when the distribution of the questionnaire to various groups of hospitals was described. The principal feature of the First Interim Report, however, was a preliminary analysis, by Mr. A. Bradford Hill, D.Sc., of the returns received before Feb. 15th from hospitals in certain groups. That preliminary analysis is now rendered obsolete by Dr. Hill’s Final Report on the material submitted to him, which is set out below.
10.
11.
12.
secondary education, school-leaving certificate, matriculation, etc.)? (Para. 16 ; Table VII.) May we have a copy of : (a) The rules sent to prospective candidates if not identical with (b)? (b) The rules handed to nurses ? Is a separate bedroom provided for each probationer ? (Para. 17 ; Table VIII.) Have you found it necessary to employ " temporary nurses "? If so, how many are working in the hospital at the present time ? (Para. 14 ; Table V.) How many domestic workers (orderlies, ward maids, or daily workers) are employed on ward duty only? (Para. 18 ; Table IX.) What is the average number of beds occupied per night over a year (Paras. 18, 19 ; Tables IX., X.) 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. (Paras. 20, 70, 71, 72, 73, 74, 75, 76.)
ii
13. 14. 15. 16.
May we have a copy of the training school prospectus ? How many probationers did you admit in : 1928, 1929, and 1930 ? (Para. 21 ; Tables XI., XIIA.) How many candidates passed the final S.R.N. last year ? (Para. 21 ; Tables XI., XIIA.) Of the nurses 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 ? (Paras. 21, 22 ; Tables XII., XIIA.) 17. What is the length of the training course? (Para. 23 ; Table XIII.) 18. Do probationers have to undertake to work for the hospital for a year after completion of training? (Para. 24 ; Table XIII.) 19. How much (if any) fee or deposit has to be paid
by probationers Table XIV.)
on
starting training
(Para. 25 ;
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 ? (Paras. 26, 27, 28, 29,
20. How much
Tables XV.,
30, 32 ; XIXA.)
XVI., XVII., XVIII., XIX.,
21. Are you affiliated to a superannuation scheme’? If so, is membership compulsory ? (Para. 33 ; Table XX.) 22. Is there a separate uniform and laundry allowance ? And if so, how much ? (a) Laundry allowance ; (b) uniform allowance. (Para. 31.) 23. Are outdoor uniforms compulsory ? If so, are
(Para. 31.)
they provided ?
24. Have you any facilities for exercise and recreation ? (Para. 34; Table XXI.) 25. Are common-rooms provided‘? (Para. 35 ; Table XXI.) 26. Are men guests admitted ? (Para. 36 ; Table XXI.) 27. Is smoking permitted in any part of the nurses’ home? (Para. 37 ; Table XXI.) 28. Have the senior nurses a latch-key ? (Para. 39 ;
Table
XXII.)
be back without a late Table XXII.) 30. Is attendance at meals compulsory even when meal-times are adjacent to off-duty hours ? (Para. 45 ; Table XXIV.) 31. What are the duty hours of nurses ? By day ; 29. What time must
pass ?
32.
33.
nurses
(Para. 38 ;
by night? (Paras. 46, 47, 52, 53, 54, 55 ; Tables XXV., XXVI., XXX.) What are hours off for meals ? Breakfast, early lunch, lunch, tea, supper. (Paras. 40, 41, 42, 43, 44, 45, 52 ; Tables XXIII., XXX.) Off-duty times and holidays : (1) Daily; (2) fortnightly; (3) weekly; (4) yearly. (Paras. 48, 49, 50, 51, 52; Tables XXVII., XXVIII.,
XXIX., XXX.) 34. Notice in advance of off-duty times and holidays : Hours off ; day off ; annual holiday. (Paras. 56, 57, 58, 59; Tables XXXI., XXXII.) 35. Night duty : Stretch of night duty ; nights per month off duty for night sister, staff nurse, probationer. Are night nurses relieved at night for meals ? (Paras. 60, 61, 62 ; Tables XXXIII.,
XXXIV.) 36. Lectures : Time of day’ ? In off duty ? In time’? (Paras. 63, 64 ; Table XXXV.)
duty
’
STATISTICAL
ANALYSIS OF THE
QUESTIONNAIRE ISSUED TO HOSPITALS BY "THE LANCET" COMMISSION ON NURSING.
FINAL REPORT SUBMITTED TO THE
COMMISSION. BY A. BRADFORD
HILL, PH.D., D.SC.
Introduction. 1. THE first interim report, published in THE LANCET of Feb. 28th, 1931, was confined to a statis. tical analysis of the replies received in answer to the first 12 questions of a long questionnaire which had been issued to 1251 hospitals by THE LANCET Commission on Nursing. That preliminary analysis has now been extended to cover, in addition, the further 24 questions which were put at the same time to all approved Training Schools1 among these 1251 hospitals. The earlier study was limited to a sample of the answers received from five groups of hospitals, viz. : Training Schools approved by the General Nursing Council for complete training,2 as represented by London Voluntary, Provincial Voluntary, and London and Provincial Municipal Hospitals, and Hospitals not approved as training schools, which were subdivided into General and Special hospitals. As well as extending the analysis to questions 13-36, the present report deals again with the answers to questions 1-12 received from five groups of hospitals dealt with in the first interim report, to which have been added further hospitals in the same categories. These are here set out, together with answers received from the seven other types of hospitals to which the questionnaire was also issued-namely, hospitals approved for partial training (Affiliated, Associated, Reciprocal),2 hospitals approved as training schools for supplementary registers (Children, Fever, Mental), and Tuberculosis hospitals ; this gives in all 12 groups (totalling 1031 hospitals), as shown in Table I., all these thousand hospitals (with the exception of certain tuberculosis hospitals) being situated in England and Wales. Questionnaires were also sent to 118 Scottish and 102 Irish hospitals within the same categories. The groups in these countries were in some cases exceedingly small (e.g., in Scotland there are only three, in Ireland only two children’s hospitals approved as training 1 Questions 18-36
were
put also to tuberculosis hospitals and
sanatoriums. 2
Complete training schools are those which have satisfied the General Nursing Council that medical, surgical, gynæcological, and children’s diseases services are provided. At least one resident medical officer must be kept, the period of training must be not less than three years, and the ratio of medical to surgical beds must not exceed 2 : 1, or be less than 1 : 2. Affiliated Hospitals are not considered sufficiently large to 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 Hospitals.—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.