- Email: [email protected]
THE FUTURE OF NURSING
1353
In England Now
Letters
4. Running Commentary by Peripatetic Correspondents THE most cautious expression of good will that I got last week was from the deputy assistant greetings officer of the North-West Lapland Regional Christmas Board Vice-chairman : Noel Noel). (Chairman : S. Claus. Writing on behalf of an executive committee whose names seemed strangely familial, this officer wrote : I am instructed to wish you one notional full session half session " deleted] of duly authorised merriment on Christmas Day, and also I am instructed to convey permission from the Board for you to be wished your full allocation of happiness and prosperity on a maximum full-time " basis [" on a part-time basis 9½/11ths deleted] commencing on 1 Jan. ’57 and continuing until 1 Jan. ’58 unless terminated by the Board’s Representatives before that date. No prosperity or happiness wished to you by the executive committee is guaranteed by the Board, and it must be clearly understood they cannot be held responsible if you do not receive your accredited allowance, which has been calculated in accordance with Article 5 of the Terms and Conditions of Christmas Wishes for Medical and Dental Staff (England and Wales, 1956). If you wish to make a appeal against the decision of the Committee, you are requested to attend at Regional Offices 6.0 p.m. Boxing day ; sherry. ...
[" one
*
*
*
No British visitor to Denmark can feel that he has travelled far from home. On landing at Kastrup only two things may remind him that he is no longer in Colchester : the language and the cyclists-and especially the cyclists. In England the cyclist pursues a furtive course, evading as best he may the cars that edge him off the road, yet doggedly refusing to ride on the special tracks where they are occasionally provided for his use. In Copenhagen, on the other hand, the cyclist meets the motorist on equal terms at the roundabouts. Elsewhere he must stick to the bicycle track set between sidewalk and road ; and this he does gladly, making sure that (as the law also prescribes) his track is inviolate. One day, stepping from A a car I put one tentative foot on one of these tracks. passing cyclist, who looked quite sober, let loose a majestic volley of oaths which carried him on his way until his back was a distant speck. One explanation of the Danish cyclists’ lack of hesitatioIL in proclaiming their rights is that they are numerous and therefore a political force. But are they not right to prefer order to anarchy ? *
*
*
The leader on Smell (Dec. 15) reminds me of Kipling’s poem Lichtenberg in The Five Nations. It describes very vividly the way that memory of a smell clings about the brain ; and suggests support for a direct connection between the cortex and the olfactory bulb. The poem begins with a most attractive alliteration : Smells are surer than sounds or sights To make your heart-strings crack’
.
*
*
*
The atomic age dates from the work of J. J. Thomson, Cavendish professor of experimental physics at Cambridge, who was born on Dec. 18 a hundred years ago. , In 1918, when I took the first M.B. I was examined in practical physics by J. J., whom I instantly recognised from his photographs, and by a young man who was later to become professor of physics at my hospital in London. I often wondered why J. J. at the height of his eminence spent his time examining students. Many years later I learned the true answer from his co-examiner, who said that J. J. believed in taking his full share of all the routine work of his department. Such is greatness. *
*
*
She has been coming to my follow-up clinic for two years with effort angina. This had been gradually progressive. When I saw her three months ago she was restricted to 600 yards at a slow pace. When she turned up again yesterday I was surprised to be told that she was cured-her new doctor’s tablets were wonderful. Sceptically I questioned her. " How far can you go now ? " " Oh, well, I never go walking without my little dog and he is rather old. He likes to stop occasionally and then we go on."
to
the Editor
THE FUTURE OF NURSING
SIR,—The problems of nurse training, put before us by Dr. Ritchie Russell in your issue of Dec. 15, are vexing and difficult, and their urgency has been greatly accentuated by the continued shortage of recruits and the unhappy wastage amongst those in training. The causes of this shortage and wastage are many, and they are well understood : there is the gap between school leaving age and 18 years, which the General Nursing Council in their nostalgic Victorian wisdom lay down as proper for training to begin ; there is the competition by educational, business, and industrial careers, which offer freedom after 6 P.M., free weekends, and in some cases financial betterment ; and there is of course marriage, which accounts for about 121/2% of the whole. Much more is now required of nurses than just basic nursing. Nurses are expected to shoulder greater responsibility, to carry out complicated techniques, to perform duties formerly given to medical students and residents, and even to participate in research projects ; and the multiplication of specialties has added in no little way to the worries of those engaged in nurse training. Those responsible, therefore, for this training have now to provide, on the one hand, nurses who are able to carry out these advanced techniques and who possess high administrative ability, and on the other hand, to provide large numbers of reliable practical basic nurses to meet the present needs of probably three-quarters of the nursing in our hospitals and institutions. It was to meet this latter need that the State Enrolled Assistant Nurse was brought into being. Recruitment, however, for this grade has so far been disappointing and the reasons are not far to seek. Apart from the inhibiting factors to recruitment already mentioned, which are common to both grades of present-day nurse training, there are the added disadvantages of the inferior title and the shut door at the end of the two years’ course for assistant nurses. This foolish attitude towards the assistant nurse should now come to an end without further delay. Dr. Ritchie Russell’s suggestion that there should be a single National basic course, constructed on the more practical basis of the present assistant-nurse training, should receive earnest consideration, and the status of " nurse," and the " open door " to further training and development by those who have shown ability, should be freely acceded. There is, however, a very important consideration which must be fairly and squarely faced. There are many responsible people in the nursing profession who feel very strongly that the downgrading of the present student’s course would make nursing unattractive to those school-leavers whose educational standards and urge for high attainment require satisfying. The loss to nursing of this important group might be catastrophic. It is just this important criticism against the lowering of standards which brought forth the proposal by Miss J. M. Akester (D.N. Lond.) in the Nursing Times of August 19, 1955, that the present nurse training " set up should be replaced by a university five years’ nursing course to run parallel with a two years’ practical basic course which would carry with it the full status of nurse together with the open door at’ the end. This kind of reconstruction is also envisaged in the recent statement of policy from the Royal College of Nursing and both are worthy of careful consideration. The chief criticism which can be brought against these proposals are that we should still have two grades of nurses with a possible implication that only those who take the university course would be likely to obtain the higher appointments even if the door was open to those nurses who had taken the shorter course. This criticism is probably not a very strong one,
1354 because -there will
Possibly
always be plenty of room at the top. important still is the undoubted fact that pick your " high ups " at the start of training
more
you cannot any more than you
decide upon your medical and surgical consultants at an initial stage. A five years’ university nursing course would entitle a successful candidate to the assurance of high office ; yet we know quite well that the qualities which make the responsible sister and the administrative officer are not necessarily educational, nor are they always visible across the preliminary interviewing table-and there’s the rub ! C. WILFRED VINING. Leeds, 1. can
SIR,—I cannot agree with Dr. Ritchie Russell’s conclusions, but I have considerable sympathy with The logic of necessity suggests some his approach. modification of the national standard for the training of the assistant nurse. On the other hand this would not absolve the profession from preparing a number of The health people as leaders and administrators. an in with services, expanding concept of health, coping will increasingly need nurses able to play their part at all levels, with a sound general background as well as On the whole it is true a good professional education. also that both the Armed Forces and the Civil Service, as well as many branches of industry, have found that promotion from the ranks does not work so well as preparation for leadership from the start. I share Dr. Russell’s doubts about the need to set the lower age-limit at 18. The prospective registered nurse would not be admitted to training until she had secured university entrance, which would be about the age of 18 ; but I can see no reason why, in the absence of such an academic requirement, a girl of 17 should not be able to face up to sickness and death, the natural heritage, after all, of every one of us. Are we not becoming a little squeamish about death, and hiding it, as the Victorians hid sex, from our young, until they come to fear it, not " as children fear to go in the dark," but as taboo ? Lastly, surely the liaison between ward sister, district nurse, health visitor, and occupational-health nurse is intended to be administrative rather than clinicalto ensure the patient has continuous care, not to prescribe the form it shall take. I am certain that most nurses would be as anxious as Dr. Russell that they should not trespass on the province of the doctor. BRIAN V. WATKIN. London, S.W.17.
suitable unless their intelligence quotient is average, or above average, in which case they may complete the course.
Ability- to benefitfrom a theoretical course—as distinct from being able to cope with it—depends on intelligence, memory, interest, motive for wanting to learn, and’ anaverage fluency in English. A favourable combination, nevertheless, seems to be an average intelligence, allied The method devised by Mr. to a " good " memory. Haward is incomplete, and will remain so until recognition is offered to the " aurists " as well as to the visualists, and when retention after selection is assessed. An excellent mechanical memory has been known to compensate for low intelligence-intelligence in terms of seeing relations between facts. It may be that this method will serve as a means to an end if the cry of do not encourage a mechanical memory alone " is made by a specific standard. Is it true that nothing comes out of nothing—nihil ex nihilo fit? T. ROBERTS "
Runwell
Hospital. Wickford, Essex.
Principal Tutor,
Nurses’ Training Department.
NEPHROGENIC DIABETES INSIPIDUS SIR,—I would like to congratulate Dr. Carter and. Dr. Simpkiss on showing so convincingly (Nov. 24) that the mothers of boys with sex-linked nephrogenic diabetes insipidus show defective urinary concentration in response to dehydration and a diminished antidiuresis after
vasopressin (’
Pitressin
’).
This
being
a
very
At Hammersmith Hospital in 1951 I did some antidiuresis tests on the mother of a boy with nephrogenic (vasopressinOn close questioning she resistant) diabetes insipidus. admitted to a mild polyuria which had never troubled her greatly. At that time we were unaware of Forssman’s observations on such mothers.’ The mother of this child was unable 1.
Forssman, H.
Acta. med. scand. 1945, suppl. 159.
(a) Test the degree of retention after selection. Extraction one thing, retention another. (b) Attempt to assess the degree of concentration as a to retention and
the " is not
recall.
writing " fluency of the student. Fluency in reading a qualification " for writing. I am of opinion that, under present-day difficulties, the (c) Test
’’
most efficient method is the one which incorporates an intelligence test and a four-week trial period in a preliminary-training school. The average score in the subjects of anatomy and physiology, and personal communal health at the end of the four-week trial is the criterion in judging the relative suitability of each student. Using this method I found that the mean difference between the average score at the end of the trial period and the score at the end of the three months in the training-school for 35 students was 4 (S.D. = 1.9). Students scoring less than 30% at the end of the period are not considered
on
’
SiR,,-The letter by Mr. L. R. C. Haward (Dec. 15) is most interesting though not wholly convincing. It would be of help if one knew the existing correlation between the intelligence as tested, and the ability to read analytically and understand technical matter, for each student. I consider that the method devised does not
prelude
dis-
record.
A SIMPLE SELECTIVE TEST FOR NURSES
is
rare
order, I feel that the following data should be put
Responses
to intravenous
vasopressin and nicotine.
In England Now
Letters
4. Running Commentary by Peripatetic Correspondents THE most cautious expression of good will that I got last week was from the deputy assistant greetings officer of the North-West Lapland Regional Christmas Board Vice-chairman : Noel Noel). (Chairman : S. Claus. Writing on behalf of an executive committee whose names seemed strangely familial, this officer wrote : I am instructed to wish you one notional full session half session " deleted] of duly authorised merriment on Christmas Day, and also I am instructed to convey permission from the Board for you to be wished your full allocation of happiness and prosperity on a maximum full-time " basis [" on a part-time basis 9½/11ths deleted] commencing on 1 Jan. ’57 and continuing until 1 Jan. ’58 unless terminated by the Board’s Representatives before that date. No prosperity or happiness wished to you by the executive committee is guaranteed by the Board, and it must be clearly understood they cannot be held responsible if you do not receive your accredited allowance, which has been calculated in accordance with Article 5 of the Terms and Conditions of Christmas Wishes for Medical and Dental Staff (England and Wales, 1956). If you wish to make a appeal against the decision of the Committee, you are requested to attend at Regional Offices 6.0 p.m. Boxing day ; sherry. ...
[" one
*
*
*
No British visitor to Denmark can feel that he has travelled far from home. On landing at Kastrup only two things may remind him that he is no longer in Colchester : the language and the cyclists-and especially the cyclists. In England the cyclist pursues a furtive course, evading as best he may the cars that edge him off the road, yet doggedly refusing to ride on the special tracks where they are occasionally provided for his use. In Copenhagen, on the other hand, the cyclist meets the motorist on equal terms at the roundabouts. Elsewhere he must stick to the bicycle track set between sidewalk and road ; and this he does gladly, making sure that (as the law also prescribes) his track is inviolate. One day, stepping from A a car I put one tentative foot on one of these tracks. passing cyclist, who looked quite sober, let loose a majestic volley of oaths which carried him on his way until his back was a distant speck. One explanation of the Danish cyclists’ lack of hesitatioIL in proclaiming their rights is that they are numerous and therefore a political force. But are they not right to prefer order to anarchy ? *
*
*
The leader on Smell (Dec. 15) reminds me of Kipling’s poem Lichtenberg in The Five Nations. It describes very vividly the way that memory of a smell clings about the brain ; and suggests support for a direct connection between the cortex and the olfactory bulb. The poem begins with a most attractive alliteration : Smells are surer than sounds or sights To make your heart-strings crack’
.
*
*
*
The atomic age dates from the work of J. J. Thomson, Cavendish professor of experimental physics at Cambridge, who was born on Dec. 18 a hundred years ago. , In 1918, when I took the first M.B. I was examined in practical physics by J. J., whom I instantly recognised from his photographs, and by a young man who was later to become professor of physics at my hospital in London. I often wondered why J. J. at the height of his eminence spent his time examining students. Many years later I learned the true answer from his co-examiner, who said that J. J. believed in taking his full share of all the routine work of his department. Such is greatness. *
*
*
She has been coming to my follow-up clinic for two years with effort angina. This had been gradually progressive. When I saw her three months ago she was restricted to 600 yards at a slow pace. When she turned up again yesterday I was surprised to be told that she was cured-her new doctor’s tablets were wonderful. Sceptically I questioned her. " How far can you go now ? " " Oh, well, I never go walking without my little dog and he is rather old. He likes to stop occasionally and then we go on."
to
the Editor
THE FUTURE OF NURSING
SIR,—The problems of nurse training, put before us by Dr. Ritchie Russell in your issue of Dec. 15, are vexing and difficult, and their urgency has been greatly accentuated by the continued shortage of recruits and the unhappy wastage amongst those in training. The causes of this shortage and wastage are many, and they are well understood : there is the gap between school leaving age and 18 years, which the General Nursing Council in their nostalgic Victorian wisdom lay down as proper for training to begin ; there is the competition by educational, business, and industrial careers, which offer freedom after 6 P.M., free weekends, and in some cases financial betterment ; and there is of course marriage, which accounts for about 121/2% of the whole. Much more is now required of nurses than just basic nursing. Nurses are expected to shoulder greater responsibility, to carry out complicated techniques, to perform duties formerly given to medical students and residents, and even to participate in research projects ; and the multiplication of specialties has added in no little way to the worries of those engaged in nurse training. Those responsible, therefore, for this training have now to provide, on the one hand, nurses who are able to carry out these advanced techniques and who possess high administrative ability, and on the other hand, to provide large numbers of reliable practical basic nurses to meet the present needs of probably three-quarters of the nursing in our hospitals and institutions. It was to meet this latter need that the State Enrolled Assistant Nurse was brought into being. Recruitment, however, for this grade has so far been disappointing and the reasons are not far to seek. Apart from the inhibiting factors to recruitment already mentioned, which are common to both grades of present-day nurse training, there are the added disadvantages of the inferior title and the shut door at the end of the two years’ course for assistant nurses. This foolish attitude towards the assistant nurse should now come to an end without further delay. Dr. Ritchie Russell’s suggestion that there should be a single National basic course, constructed on the more practical basis of the present assistant-nurse training, should receive earnest consideration, and the status of " nurse," and the " open door " to further training and development by those who have shown ability, should be freely acceded. There is, however, a very important consideration which must be fairly and squarely faced. There are many responsible people in the nursing profession who feel very strongly that the downgrading of the present student’s course would make nursing unattractive to those school-leavers whose educational standards and urge for high attainment require satisfying. The loss to nursing of this important group might be catastrophic. It is just this important criticism against the lowering of standards which brought forth the proposal by Miss J. M. Akester (D.N. Lond.) in the Nursing Times of August 19, 1955, that the present nurse training " set up should be replaced by a university five years’ nursing course to run parallel with a two years’ practical basic course which would carry with it the full status of nurse together with the open door at’ the end. This kind of reconstruction is also envisaged in the recent statement of policy from the Royal College of Nursing and both are worthy of careful consideration. The chief criticism which can be brought against these proposals are that we should still have two grades of nurses with a possible implication that only those who take the university course would be likely to obtain the higher appointments even if the door was open to those nurses who had taken the shorter course. This criticism is probably not a very strong one,
1354 because -there will
Possibly
always be plenty of room at the top. important still is the undoubted fact that pick your " high ups " at the start of training
more
you cannot any more than you
decide upon your medical and surgical consultants at an initial stage. A five years’ university nursing course would entitle a successful candidate to the assurance of high office ; yet we know quite well that the qualities which make the responsible sister and the administrative officer are not necessarily educational, nor are they always visible across the preliminary interviewing table-and there’s the rub ! C. WILFRED VINING. Leeds, 1. can
SIR,—I cannot agree with Dr. Ritchie Russell’s conclusions, but I have considerable sympathy with The logic of necessity suggests some his approach. modification of the national standard for the training of the assistant nurse. On the other hand this would not absolve the profession from preparing a number of The health people as leaders and administrators. an in with services, expanding concept of health, coping will increasingly need nurses able to play their part at all levels, with a sound general background as well as On the whole it is true a good professional education. also that both the Armed Forces and the Civil Service, as well as many branches of industry, have found that promotion from the ranks does not work so well as preparation for leadership from the start. I share Dr. Russell’s doubts about the need to set the lower age-limit at 18. The prospective registered nurse would not be admitted to training until she had secured university entrance, which would be about the age of 18 ; but I can see no reason why, in the absence of such an academic requirement, a girl of 17 should not be able to face up to sickness and death, the natural heritage, after all, of every one of us. Are we not becoming a little squeamish about death, and hiding it, as the Victorians hid sex, from our young, until they come to fear it, not " as children fear to go in the dark," but as taboo ? Lastly, surely the liaison between ward sister, district nurse, health visitor, and occupational-health nurse is intended to be administrative rather than clinicalto ensure the patient has continuous care, not to prescribe the form it shall take. I am certain that most nurses would be as anxious as Dr. Russell that they should not trespass on the province of the doctor. BRIAN V. WATKIN. London, S.W.17.
suitable unless their intelligence quotient is average, or above average, in which case they may complete the course.
Ability- to benefitfrom a theoretical course—as distinct from being able to cope with it—depends on intelligence, memory, interest, motive for wanting to learn, and’ anaverage fluency in English. A favourable combination, nevertheless, seems to be an average intelligence, allied The method devised by Mr. to a " good " memory. Haward is incomplete, and will remain so until recognition is offered to the " aurists " as well as to the visualists, and when retention after selection is assessed. An excellent mechanical memory has been known to compensate for low intelligence-intelligence in terms of seeing relations between facts. It may be that this method will serve as a means to an end if the cry of do not encourage a mechanical memory alone " is made by a specific standard. Is it true that nothing comes out of nothing—nihil ex nihilo fit? T. ROBERTS "
Runwell
Hospital. Wickford, Essex.
Principal Tutor,
Nurses’ Training Department.
NEPHROGENIC DIABETES INSIPIDUS SIR,—I would like to congratulate Dr. Carter and. Dr. Simpkiss on showing so convincingly (Nov. 24) that the mothers of boys with sex-linked nephrogenic diabetes insipidus show defective urinary concentration in response to dehydration and a diminished antidiuresis after
vasopressin (’
Pitressin
’).
This
being
a
very
At Hammersmith Hospital in 1951 I did some antidiuresis tests on the mother of a boy with nephrogenic (vasopressinOn close questioning she resistant) diabetes insipidus. admitted to a mild polyuria which had never troubled her greatly. At that time we were unaware of Forssman’s observations on such mothers.’ The mother of this child was unable 1.
Forssman, H.
Acta. med. scand. 1945, suppl. 159.
(a) Test the degree of retention after selection. Extraction one thing, retention another. (b) Attempt to assess the degree of concentration as a to retention and
the " is not
recall.
writing " fluency of the student. Fluency in reading a qualification " for writing. I am of opinion that, under present-day difficulties, the (c) Test
’’
most efficient method is the one which incorporates an intelligence test and a four-week trial period in a preliminary-training school. The average score in the subjects of anatomy and physiology, and personal communal health at the end of the four-week trial is the criterion in judging the relative suitability of each student. Using this method I found that the mean difference between the average score at the end of the trial period and the score at the end of the three months in the training-school for 35 students was 4 (S.D. = 1.9). Students scoring less than 30% at the end of the period are not considered
on
’
SiR,,-The letter by Mr. L. R. C. Haward (Dec. 15) is most interesting though not wholly convincing. It would be of help if one knew the existing correlation between the intelligence as tested, and the ability to read analytically and understand technical matter, for each student. I consider that the method devised does not
prelude
dis-
record.
A SIMPLE SELECTIVE TEST FOR NURSES
is
rare
order, I feel that the following data should be put
Responses
to intravenous
vasopressin and nicotine.