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THE STUDENT NURSE
424 four of virgin snow. A fully dilated os, with no midwife, and the patient staying with friends, proves necessity the mother of invention. So I turn another page of my B.-W. diary only to carry forward the unvisited mother of the mid-week. A message that the infant has a cold brings a fresh problem. The four roads are still closed, but the railway has been cleared, so I propose the midday train. By telephone a farmer has promised a tractor at the siding and the railway company a goods engine if I miss the return train. As I doze in the warm corner seat I wonder what the redtasselled head will think of a visit by jeep tomorrow. *
*
*
thinking of the details of a national health service one sees that what is lacking is a comprehensive body of agreement as to what we want-in short, a philosophy. Without this we are but tinkering at various and differing parts of a system, dealing with a loose brick here, adding a cornice there, like a pack of jobbing builders. Our aim, as I see it, is to make it safe to live ; but ultimately happiness and peace in living is more important than mere physical integrity. In our efforts to produce a healthy body do we think enough of the man within it ? If he will, he can make hay of all our planning. Perhaps In
we
had better take counsel with him. *
*
*
From earliest Childhood, Albert South Was given to Placing in his Mouth ’Whatever Objects, square or round, He saw reposing on the Ground. His mother wept, his father said, (Sending him, in Disgrace, to Bed) " Don’t pick up candy from the floorYou don’t know where it’s been before." His kind relations, each in turn Bawled in his ear and beat his stern But made no progress, even so, Against his Oral Libido. I cannot tell that Albert paid The slightest heed to what they said ; He scavenged still, grew rude and wild, More like a Pig Bin than a Child, Turning from wholesome Bread and Butter To Toffee Apples from the Gutter ; Until at last he chanced to meet A Box of Tablets in the street. ,
*
*
*
The pills went down, the pulse went up : He did not come to dine or sup-’ And when his Relatives arose
They found him lying Comatose. The great Consultants held out hopes And squinted down Ophthalmoscopes, Owning that Albert had them beaten Unless ’twas something that he’d eatenUntil that night, before the News, They heard a Notice from the screws That Mrs. B, the fast old witch, Had dropped some pills in Putney, which, Consumed unbid by medicos, Might dorsiflex the taker’s toes, And persons having Information Should Telephone the Nearest Station. The Great Consultants all looked grim, And each in turn remarked " That’s him" And tried to resurrect young.Bert With Picrotoxin, and a Squirt.
to
the Editor
THE STUDENT NURSE
SIR,—The General Nursing Council’s efforts to decide what is " proper training " are hampered because hospital authorities have never decided what is the work of a nurse and how many nurses are required to do it. This is not to whitewash the G.N.C., for they should long ago have realised the difficulty and acquired the necessary powers to deal with it, or as you put it matched power with -responsibility. In consequence we are faced with a muddled situation whose dominating feature is that " student " nurses must undertake to perform the routine work of the hospital in return for teaching which may be quite inadequate and has never been properly planned The result is that on sound modern educational lines. a high proportion leave (up to 60 % in many hospitals), and it looks as if we shall never know what a paradise for patients (and staff) a hospital run with fully trained personnel might be. These methods date from 1860. All we have done since is to call the probationer a student nurse and pile upon her a more and more detailed study of anatomy and physiology and other things, without any reconsideration of what she wants it for or whether she wants it at all. On the one hand we have the dismal pronouncements of those who want nurses to be devoted and dutiful (and dull), and would cut out from their training everything thrilling in modern medical science-at a time when it is more exciting than at any time in its history. On the other hand we have the nurse educationists, who, feeling the limitations of their own anatomical education, would load the nurse with every facet of the vertebrae andthe - functions of the obscure thymus in the vain hope that thereby professional status will be advanced. It is obviously impossible to change the present state of affairs overnight, but the time has surely come when the question of a curriculum and training programme for nurses belongs to national educational policy. It has become too large a matter for the General- Nursing Council. I suggest that the Interdepartmental Committee (whose report is eagerly awaited), now sitting under the chairmanship of Sir Robert Wood, of the Ministry of Education, should form the nucleus of a commission entrusted with the task of preparing a training programme and curriculum for nurses. In this connexion the report on ’practical nursing of a working committee appointed by the United States Office of Education1 and recently published is well worth study. Such a commission would have to take into account the fact that if patients are to get the attention they need there is room within the nursing profession for women of both simple and advanced educational attainments. Also that the hospital community, like a hotel or a household, requires much personal and domestic service which should be skilled but is not specifically nursing. These and many other considerations, still imperfectly understood, would influence the content of the curriculum and the manner of training. In my judgment the curriculum -and training programme, whatever the type of candidate, should have the following features:1. It even
should
exciting
be intrinsically interesting and satisfying, to those who study it ; therefore it must
be flexible. 2. It should be possible, especially in the basic course, to make a distinction between teaching given to excite interest and stimulate further observation and study in those capable of it, and fundamental facts and skills on which the safety of the patient and the efficiency of his treatment
MORAL
Learn from the Fate of Albert South Not to put Salvage in your Mouth (For Wholesome Children make no bones About their Erogenic Zones) But place it in the Bin close byAnd, should you ever Qualify, When treating folk like Mrs. B Don’t let the Chemist make too free ; Don’t dish out tablets by the Gross, But stick her on a Weekly Dose, For Doctors who their Powers abuse May be Announced before the News. (I wouldn’t write this Sort of Stuff If my Stipendium were Enough.)
Letters
_
;
depend. 3. Onlv the fundamental facts and skills should be the subject of compulsory examinations; these should be devised in the simplest possible manner but should demand high marking for pass. 1. Practical Nursing. An Analysis of the Practical Nurse Occupation with Suggestions for the Organization of Training Programs. (Misc. No. 8) Federal Security Agency, Vocational Educational Division, Office of Education. Published by the United States Government Printing Office. 55 cents.
425 4. The
significance
of
nursing and the importance of the
nurse’s part as a citizen and as a key person in the National Health Service and in her own hospital should be stressed, so that the nurse in training has a sense of pioneering, of adventure, and of social importance. 5. A diversity of post-certificate courses up to university level should be planned to succeed the basic course, and these would precede promotion and specialisation. As to anatomy, physiology, and psychology, these terms should disappear from the basic course (if only because they lose their meaning unaccompanied by the experimental studies which nurses cannot undertake). In their place the structure and function of the living body and mind should be studied, and should be taught in non-technical language by experts (not necessarily doctors or nurses, unless they are in fact experts) willing to give the very large amount of time and energy necessary for this type of teaching. The best illustration I know is Sir Arthur Keith’s Engines of the Human Body, lectures given to a juvenile audience at the Royal Society; and what a lot of trouble he must have taken over them ! The application of this knowledge should be at the bedside. It should include recognition of surface markings necessary for treatment : e.g., location of orifices ; recognition of failure of function due to structural defect and damage (the mouth no longer self-cleansing, the skin unable to maintain its resistance against pressure, the heart no longer an efficient. pump, the blood depleted of its oxygen) ; recognition of behaviour influenced by fear, suspicion, and pain (the patient operated upon for cataract suddenly plunged into outer
darkness). All these are matters for an expert educational body, which could draw upon the special knowledge possessed by members of the General Nursing Council. Most nurses would probably agree that the time has come to link up the education of nurses with the general educational system of the country. G. B. CARTER. ’
SIR,—You put forth important question :
a
proposition which
opens up
an
" Education, alike for medicine and for nursing, should, suggest, be directed towards the good of the sick-not
TYPHOID-PARATYPHOID (Vi) VACCINE SIR,—It was interesting to read in the Bulletin of Hygiene last September (p. 615) the résumé of an article by Ruiz Merino1 own a new typhoid-paratyphoid vaccine with brilliant green, for which better results are claimed both in animals and in, humans than with alcoholised, phenolised, or other types of vaccine. If this and other advantages are confirmed the vaccine will undoubtedly be a great help in the fight against enteric fever, particularly in the tropics. Some time ago, in an attempt to find out if an effective typhoid vaccine with potent Vi antigen could be pro-duced without alcohol, which was very expensive at that time, I tried several chemical and physical methods to kill the organism without affecting the Vi antigen. The simplest and most effective method found (brilliant green was not tried) was to sterilise the bacterial suspension with merthiolate, which was subsequently used in weaker concentration to maintain sterilitythe principle used by Felix in his alcoholised vaccine. The effective concentration for killing the bacterium was found to be 1 in 10,000, and the preservative strength 1 in 20,000 to 1 in 30,000. Rainsford tried higher concentrations and discarded the vaccine as unsuitable. The vaccine was stored in the cold, and at intervals of about a fortnight it was agglutinated against pure Vi-agglutinating sera and was found to keep its Viagglutinability undiminished up to 4 months, with only It compared a slight drop during the next 3 months. verv favourably with alcoholised vaccine prepared by Felix’s method and stored under identical conditions. Its protective and agglutinogenic properties have, however, not yet been fully determined.. A small number of people were inoculated with it, and its Vi-agglutinin response appeared to compare favourably with that following the injection of alcoholised vaccine. No claim can yet be made that this vaccine is superior to others, except on the grounds that it is simple to prepare and reactions to injection are few, and only mild and transient. Under post-war conditions it is not now possible to carry out any extensive investigation with this vaccine here, and we hope that workers more favourably situated may be interested in it. N. K. SEN. Department of Bacteriology, College of Medicine, Singapore.
we
towards
advancing
the status of nurse
or
But the status of the nurse is in fact in danger at present. The tendency is to regard her from the industrial standpoint and to concentrate attention on such matters as hours, wages, and what is virtually output, as though she were a producer ; and to limit her education at the same time to just what is necessary to carry out bedside
nursing. But
a nurse
is not
a
in
producer ; she belongs
a
very
good.sense to the class of the guardians of the people. Accordingly she herself and all connected with her welfare should -resist the attempt to lower her status to that of the artisan. On this view the broadest life, the widest outlook, and the best education should be hers; nothing but good should flow into eye and ear; and the aim of her teachers should be to produce first a good nurse and next a good woman. If the difficulty in recruiting nurses were approached from the standpoint, "What can I put into her?"" instead of What can I get out of her ? " then the difficulty would most likely dwindle and disappear. If the worst thing in the past were to treat her as a nun, ,
"
the worst thing at present is to look upon her
as
an
artisan. The complaint cited in your page, sir, that the nurse of today is not being trained primarily to care for the sick, comes, one notes, from an American source. To the best of my knowledge and belief there is no deterioration in the nurse’s care of the sick in this country. It might be maintained that if nursing were raised to the highest status there would still not be enough nurses. In that case two classes of nurse would be necessary, one with the equivalent of an honours and one with a pass degree ; but one hopes that this would not occur. Orpington. H. ST. H. VERTUE. _
TREATMENT OF TUBERCULOSIS
doctor."
SIR,—Your correspondent, Dr. J. V. Hurford (Feb. 15), is concerned lest undue emphasis be put upon my statement respecting the recovery of many patients from tuberculosis, who before radiography had been unaware of its presence and had not received any institutional treatment. He suggests that I base my opinion on the radiographic evidence of primary tuberculous infection rather than on post-primary progressive tuberculosis. From a serial radiography of patients with tuberculosis I have learnt that we cannot assess the gravity of past disease from the present radiographic appearances. Though we can be amazed at the spectacular spread of the progressive disease, we can be perhaps even more amazed at the disappearance, or almost complete disappearance, of spectacular radiographic " lesions." We can see " minimal " calcified foci in the lungs of most patients who are suffering from acute bone tuberculosis. We have seen patients with such " healed " lesions develop progressive and even fatal tuberculosis. For these reasons I opposed the opinion of the advocates of mass radiography that such lesions should be ignored as if they indicated established immunity : they should call for advice and added care against any influence which might lower the resistance. I fully support the views on the " old-fashioned sanatoria so ably expressed by Dr. J. H. Crawford (Feb. 8) and Dr. Temple Clive (Jan. 25). The claim put forward, that with increased surgical and other interference the five-year survival-rate has increased, has little to support it. The number of deaths from pulmonary tuberculosis has been progressively declining with improvement in social conditions ; it fell from in 1916 to 27,176 in 1928-i.e., before these 53,858 " heroic " measures were adopted. With the increased 1. Ruiz
Merino, J.
Rev. Sanid.
Hig. publ., Madr. 1946, 20,
460.
*
*
thinking of the details of a national health service one sees that what is lacking is a comprehensive body of agreement as to what we want-in short, a philosophy. Without this we are but tinkering at various and differing parts of a system, dealing with a loose brick here, adding a cornice there, like a pack of jobbing builders. Our aim, as I see it, is to make it safe to live ; but ultimately happiness and peace in living is more important than mere physical integrity. In our efforts to produce a healthy body do we think enough of the man within it ? If he will, he can make hay of all our planning. Perhaps In
we
had better take counsel with him. *
*
*
From earliest Childhood, Albert South Was given to Placing in his Mouth ’Whatever Objects, square or round, He saw reposing on the Ground. His mother wept, his father said, (Sending him, in Disgrace, to Bed) " Don’t pick up candy from the floorYou don’t know where it’s been before." His kind relations, each in turn Bawled in his ear and beat his stern But made no progress, even so, Against his Oral Libido. I cannot tell that Albert paid The slightest heed to what they said ; He scavenged still, grew rude and wild, More like a Pig Bin than a Child, Turning from wholesome Bread and Butter To Toffee Apples from the Gutter ; Until at last he chanced to meet A Box of Tablets in the street. ,
*
*
*
The pills went down, the pulse went up : He did not come to dine or sup-’ And when his Relatives arose
They found him lying Comatose. The great Consultants held out hopes And squinted down Ophthalmoscopes, Owning that Albert had them beaten Unless ’twas something that he’d eatenUntil that night, before the News, They heard a Notice from the screws That Mrs. B, the fast old witch, Had dropped some pills in Putney, which, Consumed unbid by medicos, Might dorsiflex the taker’s toes, And persons having Information Should Telephone the Nearest Station. The Great Consultants all looked grim, And each in turn remarked " That’s him" And tried to resurrect young.Bert With Picrotoxin, and a Squirt.
to
the Editor
THE STUDENT NURSE
SIR,—The General Nursing Council’s efforts to decide what is " proper training " are hampered because hospital authorities have never decided what is the work of a nurse and how many nurses are required to do it. This is not to whitewash the G.N.C., for they should long ago have realised the difficulty and acquired the necessary powers to deal with it, or as you put it matched power with -responsibility. In consequence we are faced with a muddled situation whose dominating feature is that " student " nurses must undertake to perform the routine work of the hospital in return for teaching which may be quite inadequate and has never been properly planned The result is that on sound modern educational lines. a high proportion leave (up to 60 % in many hospitals), and it looks as if we shall never know what a paradise for patients (and staff) a hospital run with fully trained personnel might be. These methods date from 1860. All we have done since is to call the probationer a student nurse and pile upon her a more and more detailed study of anatomy and physiology and other things, without any reconsideration of what she wants it for or whether she wants it at all. On the one hand we have the dismal pronouncements of those who want nurses to be devoted and dutiful (and dull), and would cut out from their training everything thrilling in modern medical science-at a time when it is more exciting than at any time in its history. On the other hand we have the nurse educationists, who, feeling the limitations of their own anatomical education, would load the nurse with every facet of the vertebrae andthe - functions of the obscure thymus in the vain hope that thereby professional status will be advanced. It is obviously impossible to change the present state of affairs overnight, but the time has surely come when the question of a curriculum and training programme for nurses belongs to national educational policy. It has become too large a matter for the General- Nursing Council. I suggest that the Interdepartmental Committee (whose report is eagerly awaited), now sitting under the chairmanship of Sir Robert Wood, of the Ministry of Education, should form the nucleus of a commission entrusted with the task of preparing a training programme and curriculum for nurses. In this connexion the report on ’practical nursing of a working committee appointed by the United States Office of Education1 and recently published is well worth study. Such a commission would have to take into account the fact that if patients are to get the attention they need there is room within the nursing profession for women of both simple and advanced educational attainments. Also that the hospital community, like a hotel or a household, requires much personal and domestic service which should be skilled but is not specifically nursing. These and many other considerations, still imperfectly understood, would influence the content of the curriculum and the manner of training. In my judgment the curriculum -and training programme, whatever the type of candidate, should have the following features:1. It even
should
exciting
be intrinsically interesting and satisfying, to those who study it ; therefore it must
be flexible. 2. It should be possible, especially in the basic course, to make a distinction between teaching given to excite interest and stimulate further observation and study in those capable of it, and fundamental facts and skills on which the safety of the patient and the efficiency of his treatment
MORAL
Learn from the Fate of Albert South Not to put Salvage in your Mouth (For Wholesome Children make no bones About their Erogenic Zones) But place it in the Bin close byAnd, should you ever Qualify, When treating folk like Mrs. B Don’t let the Chemist make too free ; Don’t dish out tablets by the Gross, But stick her on a Weekly Dose, For Doctors who their Powers abuse May be Announced before the News. (I wouldn’t write this Sort of Stuff If my Stipendium were Enough.)
Letters
_
;
depend. 3. Onlv the fundamental facts and skills should be the subject of compulsory examinations; these should be devised in the simplest possible manner but should demand high marking for pass. 1. Practical Nursing. An Analysis of the Practical Nurse Occupation with Suggestions for the Organization of Training Programs. (Misc. No. 8) Federal Security Agency, Vocational Educational Division, Office of Education. Published by the United States Government Printing Office. 55 cents.
425 4. The
significance
of
nursing and the importance of the
nurse’s part as a citizen and as a key person in the National Health Service and in her own hospital should be stressed, so that the nurse in training has a sense of pioneering, of adventure, and of social importance. 5. A diversity of post-certificate courses up to university level should be planned to succeed the basic course, and these would precede promotion and specialisation. As to anatomy, physiology, and psychology, these terms should disappear from the basic course (if only because they lose their meaning unaccompanied by the experimental studies which nurses cannot undertake). In their place the structure and function of the living body and mind should be studied, and should be taught in non-technical language by experts (not necessarily doctors or nurses, unless they are in fact experts) willing to give the very large amount of time and energy necessary for this type of teaching. The best illustration I know is Sir Arthur Keith’s Engines of the Human Body, lectures given to a juvenile audience at the Royal Society; and what a lot of trouble he must have taken over them ! The application of this knowledge should be at the bedside. It should include recognition of surface markings necessary for treatment : e.g., location of orifices ; recognition of failure of function due to structural defect and damage (the mouth no longer self-cleansing, the skin unable to maintain its resistance against pressure, the heart no longer an efficient. pump, the blood depleted of its oxygen) ; recognition of behaviour influenced by fear, suspicion, and pain (the patient operated upon for cataract suddenly plunged into outer
darkness). All these are matters for an expert educational body, which could draw upon the special knowledge possessed by members of the General Nursing Council. Most nurses would probably agree that the time has come to link up the education of nurses with the general educational system of the country. G. B. CARTER. ’
SIR,—You put forth important question :
a
proposition which
opens up
an
" Education, alike for medicine and for nursing, should, suggest, be directed towards the good of the sick-not
TYPHOID-PARATYPHOID (Vi) VACCINE SIR,—It was interesting to read in the Bulletin of Hygiene last September (p. 615) the résumé of an article by Ruiz Merino1 own a new typhoid-paratyphoid vaccine with brilliant green, for which better results are claimed both in animals and in, humans than with alcoholised, phenolised, or other types of vaccine. If this and other advantages are confirmed the vaccine will undoubtedly be a great help in the fight against enteric fever, particularly in the tropics. Some time ago, in an attempt to find out if an effective typhoid vaccine with potent Vi antigen could be pro-duced without alcohol, which was very expensive at that time, I tried several chemical and physical methods to kill the organism without affecting the Vi antigen. The simplest and most effective method found (brilliant green was not tried) was to sterilise the bacterial suspension with merthiolate, which was subsequently used in weaker concentration to maintain sterilitythe principle used by Felix in his alcoholised vaccine. The effective concentration for killing the bacterium was found to be 1 in 10,000, and the preservative strength 1 in 20,000 to 1 in 30,000. Rainsford tried higher concentrations and discarded the vaccine as unsuitable. The vaccine was stored in the cold, and at intervals of about a fortnight it was agglutinated against pure Vi-agglutinating sera and was found to keep its Viagglutinability undiminished up to 4 months, with only It compared a slight drop during the next 3 months. verv favourably with alcoholised vaccine prepared by Felix’s method and stored under identical conditions. Its protective and agglutinogenic properties have, however, not yet been fully determined.. A small number of people were inoculated with it, and its Vi-agglutinin response appeared to compare favourably with that following the injection of alcoholised vaccine. No claim can yet be made that this vaccine is superior to others, except on the grounds that it is simple to prepare and reactions to injection are few, and only mild and transient. Under post-war conditions it is not now possible to carry out any extensive investigation with this vaccine here, and we hope that workers more favourably situated may be interested in it. N. K. SEN. Department of Bacteriology, College of Medicine, Singapore.
we
towards
advancing
the status of nurse
or
But the status of the nurse is in fact in danger at present. The tendency is to regard her from the industrial standpoint and to concentrate attention on such matters as hours, wages, and what is virtually output, as though she were a producer ; and to limit her education at the same time to just what is necessary to carry out bedside
nursing. But
a nurse
is not
a
in
producer ; she belongs
a
very
good.sense to the class of the guardians of the people. Accordingly she herself and all connected with her welfare should -resist the attempt to lower her status to that of the artisan. On this view the broadest life, the widest outlook, and the best education should be hers; nothing but good should flow into eye and ear; and the aim of her teachers should be to produce first a good nurse and next a good woman. If the difficulty in recruiting nurses were approached from the standpoint, "What can I put into her?"" instead of What can I get out of her ? " then the difficulty would most likely dwindle and disappear. If the worst thing in the past were to treat her as a nun, ,
"
the worst thing at present is to look upon her
as
an
artisan. The complaint cited in your page, sir, that the nurse of today is not being trained primarily to care for the sick, comes, one notes, from an American source. To the best of my knowledge and belief there is no deterioration in the nurse’s care of the sick in this country. It might be maintained that if nursing were raised to the highest status there would still not be enough nurses. In that case two classes of nurse would be necessary, one with the equivalent of an honours and one with a pass degree ; but one hopes that this would not occur. Orpington. H. ST. H. VERTUE. _
TREATMENT OF TUBERCULOSIS
doctor."
SIR,—Your correspondent, Dr. J. V. Hurford (Feb. 15), is concerned lest undue emphasis be put upon my statement respecting the recovery of many patients from tuberculosis, who before radiography had been unaware of its presence and had not received any institutional treatment. He suggests that I base my opinion on the radiographic evidence of primary tuberculous infection rather than on post-primary progressive tuberculosis. From a serial radiography of patients with tuberculosis I have learnt that we cannot assess the gravity of past disease from the present radiographic appearances. Though we can be amazed at the spectacular spread of the progressive disease, we can be perhaps even more amazed at the disappearance, or almost complete disappearance, of spectacular radiographic " lesions." We can see " minimal " calcified foci in the lungs of most patients who are suffering from acute bone tuberculosis. We have seen patients with such " healed " lesions develop progressive and even fatal tuberculosis. For these reasons I opposed the opinion of the advocates of mass radiography that such lesions should be ignored as if they indicated established immunity : they should call for advice and added care against any influence which might lower the resistance. I fully support the views on the " old-fashioned sanatoria so ably expressed by Dr. J. H. Crawford (Feb. 8) and Dr. Temple Clive (Jan. 25). The claim put forward, that with increased surgical and other interference the five-year survival-rate has increased, has little to support it. The number of deaths from pulmonary tuberculosis has been progressively declining with improvement in social conditions ; it fell from in 1916 to 27,176 in 1928-i.e., before these 53,858 " heroic " measures were adopted. With the increased 1. Ruiz
Merino, J.
Rev. Sanid.
Hig. publ., Madr. 1946, 20,
460.