ENQUIRY INTO THE SUPPLY OF NURSES 1916
As thousands of trained nurses moved from civil hospitals, private homes and work within individual communities to take up posts with the military nursing services, shortages soon became evident. It took three years to train a nurse to the standard required by both civil hospitals and the War Office and in all areas the extra pressure put upon hospitals by the enormous number of wartime casualties began to stretch resources to the maximum. A Government Committee was set up in the autumn of 1916 to investigates ways and means of improving the situation, if only by the method of robbing Peter to pay Paul. It proved a difficult task, and even the original composition of the Committee itself came under intense scrutiny, resulting in several resignations before getting underway. This document outlines the deliberations of the Committee and their findings, dated 24th January 1917.
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REPORT OF AN ADVISORY COMMITTEE APPOINTED BY THE ARMY COUNCIL TO ENQUIRE INTO THE SUPPLY OF NURSES
THE NATIONAL ARCHIVES, WO32/9343
THE NATIONAL ARCHIVES, WO32/9343
Your Committee have unanimously decided to send in the following interim report in the hope that the War Office will act upon it without delay. They regard it as of such pressing importance as not to admit of its being postponed until it can be embodied in the final report of the Committee.
It has not yet been possible for your Committee to tabulate the statistics which they are collecting as to the numbers of trained nurses and their disposal in the different hospitals at home and abroad, nor as to the number available who are not at present at work. But it seems tolerably clear that if the war continues through next year a large number of probationers will be required in addition to those at present employed.
At a time when women are being recruited for munitions, for agriculture and for many other branches of national work, it is of the highest importance that no time should be wasted in securing those who will be needed for nursing work.
In order to secure the best class of young women for nursing work, to equip them for their duties and attach them to the Services, we recommend that a central hostel should be established in London, where those who are willing to serve under a contract and have had no hospital experience could be housed under the care of a trained and experienced matron. Such matrons could arrange for theoretical lectures in the hostel, whilst the members would be allocated, with the co-operation of the authorities of civil hospitals and infirmaries, for daily work as probationers in the wards, for such periods as might be arranged.
We suggest that accommodation should be found in one or more such hostels for 500 probationers who could start work immediately. We are of the opinion that the hostel might be utilised at the same time for the training of general service members in work for military hospitals. Possibly large private houses might be lent for the purpose if an appeal were made.
These probationers should be recruited by the Voluntary Aid Detachment headquarters and vacancies filled up from the reserve lists at Devonshire House. After a month’s probation they should be reported upon by the head of their training hospital, and dismissed if unsatisfactory. If approved they should be required to sign a contract for a further term 12 months. The time spent in the hostel, which we suggest might be 3 months, should count as part of their term of service. A week’s leave at the end of these 3 months, would be desirable.
It should be clearly stated in the application forms given to intending candidates that the training given in the hostel does not carry with it any form of certificate and does not qualify the student to call herself a trained nurse. Otherwise the scheme might not receive the co-operation of the Training Schools which is essential to its success.
The expenses of the hostel might be born by the Joint War Committee, with the aid of a grant from the Admiralty and War Office.
[Signed] William C. Bridgeman, Chairman, On behalf of the Committee
14th November 1916
1. Appointment of Committee
The Committee as originally constituted consisted of the following members:-
Mr. W. C. Bridgeman, M.P., Chairman
Sir Frederick Treves, Bt., G.C.V.O.
Hon. Francis Curzon
Mrs. Charles W. Furse, R.R.C., Commandant-in-Chief, Women’s Voluntary Aid Detachments.
Captain Harold Boulton, C.V.O., Chairman of Queen Mary Hostel for Nurses
Mr. E. W. Morris, Secretary of the London Hospital
And their reference was:-
‘To consider the existing system of obtaining nurses for the hospitals for sick and wounded soldiers at home and abroad, and to make such recommendations as they may consider necessary for augmenting the supply.’
It was subsequently found necessary, on the advice of the Chairman, and for reasons of which the Army Council are aware, to make an alteration in the terms of reference and a general reconstruction of the Committee. Lord Knutsford resigned, and the following additional members were appointed:-
Miss E. H. Becher, R.R.C., Matron-in-Chief, Q.A.I.M.N.S.
Miss Sidney Browne, R.R.C., Matron-in-Chief, T.F.N.S.
Three members of the Q.A.I.M.N.S. Nursing Board:-
The Countess of Airlie
Miss L. V. Haughton, Matron, Guy’s Hospital
Miss R. Cox-Davies, R.R.C., Matron, Royal Free Hospital
Miss A. Lloyd Still, Matron, St. Thomas’ Hospital
Miss A. McIntosh, Matron, St. Bartholomew’s Hospital
Miss A. W. Gill, R.R.C., Lady Superintendent, Royal Infirmary, Edinburgh
Miss E. C. Barton, R.R.C., President, Poor Law Infirmary Matrons’ Association
Subsequently Sir F. Treves resigned, and Miss A. MacDonnell, R.R.C., representing the Irish Nurses’ Association, and Fleet-Surgeon R. W. G. Stewart, R.N., representing the Admiralty, were added to the Committee, and Lieut.-Colonel Sir James Kingston Fowler, K.C.V.O., M.D., was appointed in the place of Sir F. Treves.
The new terms of reference were:-
‘The Committee has been appointed for the purpose of ascertaining the resources of the country in trained nurses and women partially trained in nursing, so as to enable it to suggest the most economical method of utilising their services for civil and military purposes.’
2. Proceedings of the Committee
The Committee as reconstructed have met 19 times. We have examined a number of witnesses who were good enough to give evidence on various aspects of the problem, and whose names are set out in Appendix A [not printed].
We did not consider enquiries into such general questions as the status of nurses after the war, State registration of trained nurses, or length of training to be within the terms of our reference. We have, therefore, confined ourselves to such investigations as seemed necessary into the present and future supply of nurses during war-time in civil and military hospitals.
Believing that the War Office desired an early report we have limited our enquiries to what appeared to us the most urgent aspects of the problem.
We are sending in some tables containing figures as to numbers of nurses and beds in various hospitals. But as some of them may be regarded as confidential they are embodied in a separate Appendix, B [not printed].
It may be well to summarize here the evidence we received as to the conditions prevailing in the nursing institutions of the various authorities engaged in the work and to deal with the figures later.
3. Nurses engaged in Public Health work.
The Local Government Board, in addition to their Poor Law Institutions, are concerned with nurses in Isolation Hospitals, Sanatoria for tuberculosis and Health Visitors.
The Isolation Hospitals are insufficient for their requirements, and no nurses can be spared from the existing establishments.
In the Sanatoria the greater part of the nurses are not fully trained.
Of Health Visitors there are 1,117, of whom 498 work whole time and 609 part time only. Of these 537 are fully trained. The Board estimate that there should be one Health Visitor for every 500 births, and if this scale were maintained they would require between 1,600 and 1,700 for England and Wales.
A few Health Visitors have taken up nursing for the Army, but the Local Government Board deprecate any further call being made upon them.
Since the appointment of Health Visitors the rate of infant mortality has fallen from 150 to 110 per thousand births. We do not therefore think it expedient, in view of the great value of their present work, to make any further inroads on the number of Health visitors. Many of them, moreover, have had little hospital experience for many years. Some few nurses are engaged from private nursing associations by the local authorities for home nursing in infectious cases, and about 600, of whom only 50 are fully trained, are taken for midwifery work from the ranks of the District Nurses.
We do not think that it would be good policy to attempt to draw more nurses from these sources for military work.
4. Nurses in Poor Law Institutions
These institutions, with hardly any exception, find great difficulty in securing the services of trained nurses, this is attributed to the counter attraction offered by other recruiting agencies, and to the low scale of pay in some of the smaller workhouse infirmaries.
Sir A. Downes stated in his evidence that there were in London only 3,000 spare beds out of a certified accommodation of 15,783. This he regarded as a very small margin, taking into consideration the fact that there is usually a large rise in cases of sickness after Christmas.
There is, therefore, no possibility of reducing the accommodation and releasing the staff at the present time.
He informed us that the London Boards of Guardians might be able to spare 11 fully trained and 6 partly trained nurses.
He thought that retired nurses might be induced to come back to work in Poor Law Institutions, and said that in one district a good deal of help had been afforded by Voluntary Aid Detachments undertaking relief work.
They were able to get probationers, but there was not accommodation for many in excess of the present numbers in their training schools.
We are convinced that very few trained nurses can be drawn for military work from this source, apart from those shown on page 4 as completing their term of training.
5. Queen Victoria’s Jubilee Institute for Nurses
In connection with this Institute there are two classes of nurses at work, Queen’s Nurses and Village Nurses.
Of Queen’s Nurses there were before the war about 2,100 working in England, Scotland, Ireland and Wales.
Of these 650 have gone to nurse the wounded, but nearly two-thirds of the vacancies thus created in England and Wales have been filled by nurses who had previously given up work, or by nurses of inferior qualification.
The work of these nurses lies amongst the poorest of the population, and the use of large infirmaries as military hospitals has increased the amount of home nursing. Having regard to these facts, the Institute can ill afford to spare any more Queen’s Nurses.
There were about 1,230 Village Nurses before the war, most of them have received a year’s training in a training home specially adapted for the purpose, partly in midwifery and partly in general training for district work. Before being posted to work in villages they must secure the certificate of the Central Midwives Board. They have had but little training in the work required in military hospitals.
We agree with an Hon. Secretary of the Institute in thinking that it would be in the highest degree unwise to encourage more Queen’s Nurses to leave their posts, and that the gain to the wounded would be small in comparison to the loss to the future strength of the nation.
6. School Nurses
Neither the Board of Education nor the Scotch Education Department feel able to advise or encourage any more School Nurses to undertake work in military hospitals. We do not recommend that any pressure should be exercised to induce these nurses to take up war work, except in some very grave emergency.
7. Metropolitan Asylums Board
The evidence of Sir Duncombe Mann showed that the Board’s hospitals are already short of nurses and are experiencing considerable difficulty in obtaining them, although the number of infectious cases is quite exceptionally low.
Out of 7,091 beds equipped only 3,769 were occupied when he gave his evidence, and the staff consisted of 167 fully trained nurses, 335 trained in fever hospitals, 355 probationers and 429 uncertificated assistant nurses.
They were advertising for nurses in five of their hospitals, and if any great increase in infectious cases arose, their difficulties would be very serious. Some nurses trained in fever hospitals are being taken for military work as assistant nurses more rapidly that the Board are able to replace them.
We consider that the board cannot meet it obligations if more nurses are taken from their hospitals.
8. Civil Hospitals
We sent out letters of enquiry to about 1,000 civil hospitals in the United Kingdom, including general, special and infectious hospitals. A few have not replied but a sufficient number have sent returns to justify general conclusions being drawn.
The result shows the following average proportion of nurses to beds. It should be noted that in many cases nurses engaged in special departments are believed to be included in these returns. If these were excluded the number of beds per nurse would be somewhat larger:-
London Hospitals –
Trained Nurses, 1 to 13
Untrained Nurses 1 to 4
Provincial Hospitals in England and Wales –
Trained Nurses 1 to 24
Untrained Nurses 1 to 7
Scottish Civil Hospitals –
Trained Nurses 1 to 14
Untrained Nurses 1 to 5
Irish Civil Hospitals –
Trained Nurses 1 to 20
Untrained Nurses 1 to 6
9. Trained Nurses
The evidence before us tends to show that the Queen Alexandra Imperial Military Nursing Service, the Territorial Force Nursing Service, and the Joint War Committee of the Order of St. John and the British Red Cross Society have found little difficulty in securing the number of trained nurses they require. But many of these have been drawn from other services at home, and many of those services have reached the point where further depletion would be calamitous.
We are not able to ascertain with accuracy the wastage in all hospitals where military cases are being nursed. But we have the figures for the Queen Alexandra’s Imperial Military Nursing Service and the Territorial Force Nursi8ng Service, and judging from those figures we estimate the annual wastage of trained nurses tending military cases to be at least 1,400, and we think it is more like to exceed than to fall below this figure.
But in order to carry out the recommendations we are about to make for more regular leave, a total addition of 1,500 to the strength of trained nurses for military work would be necessary.
10. Future sources of supply
We have, therefore, to contemplate a requirement for next year of 2,900 more trained nurses. The future sources of supply open are the following:-
a. Those who, in the course of the next year, will have completed their training. Their numbers are:-
Poor Law Infirmaries 679
London civil hospitals 705
Provincial civil hospitals (England and Wales) 1,637
Civil hospitals, Scotland 428
Civil hospitals, Ireland 158
Perhaps two-thirds of these will be available for military nursing. We may, therefore, reckon on about 2,400 for this purpose.
b. There is always the possibility, as an extreme measure, of meeting an increasing number of casualties by reducing the proportion of trained nurses to beds in the existing hospitals.
At the present time in home hospitals, nursed by Queen Alexandra Imperial Military Nursing Service, and in war hospitals nursed locally, the average proportion is 1 to 17. In the Territorial Force Nursing Service hospitals it is 1 to 14. We think the latter figure might generally be adopted as a maximum average, and in that case no nurses can be drawn from any of these military hospitals now.
We do not recommend at the present time any attempt to reduce the proportion below the average rate of 1 trained nurse to 14 beds.
c. A considerable number of hospitals for officers only have been established both in London and the provinces by persons laudable anxious to assist the work of tending the sick and wounded, and much excellent work has been done in them for which the nation has every reason to be grateful.
To a request for information as to the number of nurses per bed in these hospitals, a certain number of replies have been received from which it appears that the proportion is:-
Trained nurses 1 to 4
Untrained nurses 1 to 6
Several of the general hospitals now have a very large number of beds permanently set apart for officers; for instance, A, a military hospital in France has 100 such beds; B, a military hospital in England has 183; C, a Territorial general hospital has 326.
The officers’ beds in A are nursed by 8 trained and 7 untrained nurses, exclusive of orderlies; in B by 25 trained and 5 untrained nurses; and in C by 26 trained and 19 untrained nurses. This gives a proportion of:-
A. Trained nurses 1 to 12
Untrained nurses 1 to 14
B. Trained nurses 1 to 7
Untrained nurses 1 to 36
C. Trained nurses 1 to 12
Untrained nurses 1 to 17
When these figures are contrasted with those given above, it is apparent that the establishment of a number of small hospitals for officers only is wasteful as regards nurses, and that, if the numbers in the private hospitals for officers were assimilated to those in the military hospitals of the same class, a considerable number of nurses would at once become available for general needs of the naval and military services.
In private hospitals for officers only we think that an appeal might be made to the managers to reduce the present proportion of trained nurses from 1 to 4 to that of 1 to 6. This would release about 50 nurses.
d. The Committee have carefully considered the evidence which has been given favouring the immediate closure of small auxiliary hospitals in order to effect the saving of nurses which would necessarily result from such a measure. It has however, been pointed out that if this were done the services of a large number of local helpers and half-time workers, as well as a considerable amount of gifts in kind, would be lost, and that this loss might outweigh the advantage to be gained.
It is perhaps natural that those in charge of these hospitals should manifest a preference, as they undoubtedly have done, for serious cases, and should regard with less favour ‘walking cases’ and convalescents, for the care of which they are from every point of view so much better equipped.
The Committee feel confident that, when it is made clear to them that the need is urgent for an increase in the number of nurses available for service abroad, they will readily accept as their share of the great work the role which considerations of economy of nursing staff prescribe.
The Committee recommend that all small auxiliary hospitals should be restricted to cases of the less serious types, and that no new hospitals of less than 40 beds should be opened.
e. There is also a certain supply which might be obtained from those who are engaged in private nursing.
There are still left on the private nursing staffs of the large civil hospitals in the United Kingdom about 500 nurses.
Numerous nursing associations and private nursing homes exist in the Metropolis and in other parts of the country, but it has not been possible to ascertain their number, or the number of nurses employed by them. An appeal to private nurses to take up military duties might yield 300 or more.
f. We understand that the Dominions might be able to supply about 1,000 more trained nurses in the course of the next year.
g. No doubt nurses might be secured in the United States, but we think that the British Empire should be able to provide her own nurses for her own men.
Adding the possible product of the first four sources we get:-
This may appear to be a sufficient margin to meet the year’s requirements of 2,900, but it must be remembered that the casualties may unhappily exceed any that have heretofore occurred.
Sir Arthur May (Medical Director-General of the Navy) has informed us that in the event of large casualties at sea, he might require 520 trained nurses (as well as 500 probationers) in addition to his present staff, and for this provision allowance must be made.
We do not, therefore, consider that the visible supplies will greatly exceed the demand. Furthermore, we feel that in order to be prepared for any great emergency which may arise, it would be well to ascertain how many probationers, including V.A.D. members might be qualified to act as nurse under a sister.
We asked matrons of war hospitals and voluntary hospitals for officers and men to give us the number of probationers who would in their opinion be equal to these duties, and the number returned amounted to 5,000.
We think that this figure may be excessive, but there is at any rate a large and increasing number which would form a very useful reserve to fall back upon, if the supply of fully trained nurses should fail.
Our recommendations on the matter of additional supply are:-
a. Continue to utilise the services of all available probationers from civil hospitals and infirmaries as they complete their training.
b. Aim at a maximum proportion of 1 trained nurse to 14 beds in men’s hospitals and 1 to 6 in private hospitals for officers.
c. Make an appeal to private nurses and to the associations and others who employ them.
d. Appeal to the Dominions for more trained nurses.
e. If the supply of trained nurses fails, use probationers [including V.A.D. members] approved by matrons under whom they have worked, to act as nurses under a sister.
11. Conditions of Service
Apart from merely numerical considerations, we believe that it is possible to make certain alterations in the conditions of service which may act as inducements to nurses to remain longer in the service, and possible attract recruits.
We hold very strongly to the opinion that the health and efficiency of the nursing staff depend upon the certainty of regular and adequate leave. If nurses continue to work beyond the limit of their strength, their break-down is serious, and in some cases permanent. This could be avoided by an increase in the trained staff.
At present there is no margin for sickness or leave, or for nursing special cases. Numbers are lost to the service because they are unable to bear the strain.
The regulation leave might be sufficient if it were absolutely regular, but more relaxation is required, so that a tired sister may be relieved without throwing extra work on other people.
We therefore recommend such an addition to the permanent staff as may enable leave to be granted with absolute regularity, and more relaxation allowed where necessary. See para. 10.
ii. Pay, Gratuities and Pensions
We understand that the new scale of pay for the war in the Queen Alexandra’s Imperial Military Nursing Reserve and Territorial Force Nursing Service is:-
Nurses. - £40 per annum, annual increment £2. 10s. up to £45 per annum plus £20 after one year’s service if they agree to sign an undertaking to serve for so long as required at home or abroad.
Sisters. - £50 per annum, annual increment £5 up to £65 per annum plus £20 after one year’s service if they agree to sign an undertaking as mentioned above.
Assistant Matrons. - £75 per annum.
Matrons. - £75 per annum, annual increment £10 up to £150 per annum.
The scale of gratuities given on completion of service is:
Nurses. - £7. 10s for each year of service
Sisters. - £10 for each year of service
Matrons. - £15 for each year of service
The War Pension rates are:-
Earning capacity totally destroyed: Matrons £50 Staff nurse or Sister £40
Earning capacity seriously affected: £40, £30
Earning capacity impaired £30, £20
We welcome the increase, but we should have liked to see a system of gratuities for nurses of £5 for each six months’ service, with an increment of £1 on the gratuity for each successive half year after the first six months, and for the other grades in proportion to be paid on the termination of service. But we think that insistence on the condition of service for the duration of the war may act as a deterrent to some who doubt their ability to face the long service which might be required. Some further inducement should be held out to those willing to sign for the duration of the war. The systems of the Queen Alexandra’s Imperial Nursing Service and the Territorial force Nursing Service should be assimilated in this respect.
We recommend this not only because we think their work fully deserves such remuneration but because we believe that nurses who now hold back for fear of finding themselves out of work at the end of the war might come forward if they knew that by this system of gratuities they would have a small sum in hand when their war work was concluded.
We regard the scale of pensions offered to nurses whose permanent break-down is due to military service as quite inadequate, and recommend that the scale should be raised to a minimum of £52 for total disablement, irrespective of rank.
iii. Messing Allowance
There appears to be some doubt if this allowance extends to Scotland. It is desirable that it should be made clear that Scotland is included, and that the Matrons and Sisters in Scotland should be allowed to draw their own messing and washing allowances as in England.
iv. Conveyance to and from work
Numerous complaints are heard of the great inconvenience and discomfort experienced by nurses whose quarters are at a distance from their work. When there are trams they are usually overcrowded.
We urgently press that in these cases a covered conveyance should be provided to transport nurses to and from their work.
Conveyances should also be provided to enable nurses in Camp Hospitals to get the necessary recreation and relaxation away from the camp. Women drivers could easily be found for this work.
v. Better accommodation
In some of the buildings and institutions, which are now being used as War Hospitals, the housing and messing accommodation for nurses is by no means comfortable.
Steps should be taken to improve the accommodation where such conditions prevail. We suggest that the Matron-in-Chief, Queen Alexandra’s Imperial Military Nursing Services, should be allowed an inspecting matron, with good pay and travelling expenses, to visit and report on all War Hospitals.
There seems to be a general feeling of doubt amongst nurses who are not supplied by the military nursing organizations, but are tending military cases in War Hospitals, Voluntary Hospitals, or wards of Civil Hospitals, that their work will not be recognized in the same way as the services of other military nurses. They also complain that they do not have the same travelling allowances.
We consider that they would be more contented with this service if their status was regarded as equal to that of other military nurses, and if it were made known that that same recognition, whether by medals or other decorations, would be extended to their service, if of sufficient duration. We also think that they should be allowed similar privileges as to cheap rates of travelling.
vii. Co-ordination of various authorities
At the outbreak of the war, nursing had been organized for a small army. The expansion of the service to meet the needs of a huge force has been a magnificent achievement, for which the highest praise is due to the organizers, and to all the different branches of the nursing world who have thrown themselves whole-heartedly into the work. No commendation is too great for this devoted service. We feel sure that the Army and the British nation recognise the incalculable debt which they owe to the nursing profession, and to the volunteers who have come forward in such numbers.
But as one extension of the work has succeeded another, we cannot help being struck by the number of different authorities engaged or affected. There are:
The Queen Alexandra Imperial Military Nursing Service.
The Territorial Force Nursing Service.
The St. John’s and Red Cross Joint Committee.
The Local Government Boards.
The Central and Local Education Authorities
The Boards of Control.
The Ministry of Munitions.
The Queen Victoria Jubilee Institute for Nurses, and many Civil Hospitals and local authorities.
With all these services under different management there must be a considerable waste of energy unless they are very closely co-ordinated and kept in touch with one another. The more attractive services draw from the less attractive, and all of them must, however much they try to avoid it, compete with each other.
For example, the Queen Alexandra Imperial Military Nursing Service may engage a nurse who has previously been working in a hospital under the Local Government Board. That hospital may fill her place by engaging a nurse who has been, up to that time, nursing in one of the institutions of the Board of Control, whilst the last-named institution may appoint in her stead a Health Visitor, and finally, a vacancy occurs among the Health Visitors. At first sight it might appear that three new nurses had been obtained. Yet, as a matter of fact, no new nurse has been secured, whilst a vacancy has been created and a great deal of trouble involved.
We suggest that an Advisory Committee should be established, on which all the larger authorities should be represented. They should act as a clearing-house. This Committee should meet at least once a month and ascertain what are the requirements of the various civil and military institutions and how far they can help each other for the period of the war.
This committee might have the duty of issuing advertisements, stating the vacancies that exist in various institutions, with a clear explanation of the proper steps to be taken in applying for a post. They could also consider arrangements for facilitating the employment of women who are not young enough for foreign service.
We have been informed that a considerable number of retired nurses are willing to offer their services, but are prevented from doing so through ignorance of the proper procedure.
12. Untrained Nurses
It appears to be generally admitted that there is no trouble in enlisting probationers for any of the branches of the nursing service where they are required.
But the difficulty felt by the V.A.D. Joint Committee is that, while it is easy to obtain offers of service, it is hard to retain on a waiting list those who are not immediately required. While they are waiting they are attracted to munition work, canteens or other duties which they can take up without delay.
The following figures, supplied by the Joint Committee, point also to a very large wastage:-
V.A.D. members posted in the last 20 months, 9,989Of this wastage, about 20% are known to have re-engaged.
V.A.D. members now at work, 7,205
This wastage is composed of members who have left for the following reasons:
Health reasons, 450
Private reasons, 604
Termination of contract, 1,531
We have received a good deal of evidence from county directors and others engaged in Voluntary Aid Detachment work, and we believe that certain improvements which we are about to suggest would not only attract more recruits of the most suitable class to V.A.D. membership, but also would lessen the present rate of leakage.
i. Expenses of candidates
These expenses, though not very large in amount, often turn the scale when a person, who will in any case have to make considerable sacrifices, is deciding whether to become a candidate or not.
We recommend that provision should be made for free medical examination of candidates.
The uniform of a V.A.D. member joining a military hospital costs about £6. 10s., towards which she only receives £2 half-yearly, though after the first half-year this allowance really goes to upkeep. We do not think they should be made to bear this expense.
In V.A.D. hospitals the War Office allowance per occupied bed is insufficient to enable the hospitals to pay for the uniform, washing, fares and, sometimes even the food of the nursing members. There are undoubtedly some V.A.D. members who cannot afford to bear this cost for a prolonged period and have had to leave in consequence.
We recommend that a further allowance should be granted where necessary to meet such cases.
ii. Grading of V.A.D. members
At the end of 13 months service V.A.D. members are given a stripe, if their conduct has been satisfactory. But the stripe does not carry with it any apparent privileges, with the consequence that there is but little incentive to try to excel. The following suggestion was made by a witness with great experience.
After a certain period of service, there might be an examination of V.A.D. members who had during that period performed their duties satisfactorily to the matrons under whom they served. The examination would be practical rather than theoretical. The successful candidates should be placed in a higher rank, and be relieved of the more menial part of their duties. If an examination is not possible, 13 months’ service with the recommendation of the matron in charge might establish the rise in grade. This distinction in grade should emanate from the Military Authorities.
From this grade the heads of the Army Nursing Service might select members to undertake the duties of nurse under a sister if the increase of casualties or the shortage of trained nurses made it necessary.
iii. Position of V.A.D. members
Many of our witnesses have called attention to cases of friction between trained nurses and V.A.D. members. On the one hand trained nurses have not always been fairly treated by untrained commandants. On the other, V.A.D. members have complained of being prevented by trained nurses from doing anything but menial duties and the work of orderlies. That such cases have occurred there can be no doubt.
One witness described them as ‘the friction of the expert and the non expert.’ It is the inevitable tendency of the amateur to be impatient of routine and strict discipline, and the natural aversion of the professional from trusting anything but the simplest duties to the beginner. There is also apparently in the minds of some of the trained nurses a suspicion that those who have entered the service as volunteers for the war will, after it is over, occupy positions of equality with themselves without having gone through the same drudgery, discipline and education in obtaining their qualifications. This suspicion appears to us to be totally unfounded, and without going into the question of the status of nurses after the war we believe that it must rest with the Training Schools to decide how much the military service of V.A.D. members shall count for in the event of their wishing to complete their training after the war.
Yet while admitting that there has been occasional trouble through this kind of friction, we are astonished that it has not been more frequent. We have been much impressed with the general smoothness with which the present anomalous system works. It is a great testimony to the devotion and unselfishness of the general body of nurses engaged. Our evidence shows that such cases of friction are diminishing. The chief nursing authorities are alive to the difficulty and, while we believe that the Joint V.A.D. Committee discourage complaints, we are convinced that where such complaints are substantiated the Military Authorities are fully prepared to investigate them.
It is obvious that such grievances, whether real or imaginary, might have a deterrent effect on the recruiting of candidates if it were not evident that the authorities are perfectly ready to do justice to them. Miss McCarthy, the Matron-in-Chief in France, informed us that the nurses and V.A.D. members worked very well together. She said of the V.A.D. members, ‘They do work extremely well, and I think the nurses look on them in the light of probationers.’ This is the right spirit. We are concerned with nursing during the war and not after the war, and we feel that any training which matrons and sisters find themselves able to give to V.A.D. members is of the utmost value. But we are well aware how little time is at the sisters’ disposal for instructing beginners, and we hope that this fact is recognized by V.A.D. members.
It is because of the high value which we attach to training, however short, that we have sent in an interim report advocating the institution in a convenient position of a hostel for 500 V.A.D. members in London, from which they can go to the different training schools. We believe that even a three months’ training, which we would gladly see extended to six months, if possible, will add enormously to the efficiency of V.A.D. members.
We would further recommend that similar hostels should be provided in some of the other great cities of the United Kingdom. We think that it will prevent the shrinkage of a waiting list, and draw the best class of young women to the work.
We would also suggest that an experienced matron should be appointed as inspector of V.A.D. auxiliary and private hospitals for each Command in the United Kingdom. the reports of these inspectors should be submitted through the different Commands to the War Office for final action.
Again we recommend that in V.A.D. Auxiliary hospitals the trained matron should be in charge of the nurses and responsible for carrying out the orders of the Medical Officer in all matters affecting the nursing of the patients, whilst the commandant, if untrained, should only undertake the secretarial work, general correspondence and accounts.
13. Private Nurses
We have been unable to ascertain with any accuracy the number of trained nurses in private practice.
Some of the large hospitals have private nursing staffs attached to them. These nurses are sent out to private cases.
There are also many nursing associations and a large number of nursing homes.
No doubt a considerable number of nurses engaged in private practice have offered their services for war work, but we believe that a larger proportion have been deterred from doing so either because they were supporting other people and could not afford to take a lower rate of pay, or because they were afraid of losing their position at the end of the war.
It is thought that many of these nurses who have been a long time in private practice, and away from hospital work would not be very suitable for duty in military hospitals.
On the other hand there must be a considerable number would be suitable.
If these are to be obtained by the Military Authorities it will probably be necessary to pay some compensation either to them or to the hospitals and associations to which they are attached.
It will also be necessary to make an appeal to them to join, and to their employers and associations to send forward names of candidates and to keep open their places so that they may resume them at the end of the war. An appeal, too, would have to be made to the medical profession to try to economise in private nurses, and to the well-to-do public to forego the luxury of private nursing except in very serious cases.
14. Conscription and General Organisation of Women
Several witnesses have suggested conscription, others that a census should be taken of all nurses employed or unemployed, and that they should be enlisted in the same way as soldiers and sign on for whatever service was required of them.
We cannot conceal from ourselves the fact that if such a procedure were possible, it would immensely facilitate the task of putting the right nurses in the right place.
Though we are not prepared to advocate the general conscription of women, we should most heartily welcome any general organization of the woman power of the country which would register all those whose training, ability and inclination fit them for the work of nursing the sick and wounded as well as for other national requirements during the war.
15. General Observations
Captain Boulton kindly undertook a visit to the hospital ships, which convinced him that the arrangements made for the supply and relief of nurses were so well organized that no saving of nurses could be advantageously effected. With the consent of the authorities he was enabled to see the nurses at work in the hospitals and clearing stations in France upon which he made many observations which have been valuable in enabling us to frame out report.
We deeply regret that Miss Haughton whose services had been of the greatest use in the earlier deliberations of the Committee has been stricken with severe illness and been thereby prevented from attending the later meetings.
We are indebted to the hospitality of the Privy council and the House of Commons and to Lord Claud Hamilton and the Directors of the Great Eastern Railway in lending rooms for meetings.
We desire to record our appreciation of the services rendered by Mr. T. R. Walrond as Secretary to the Committee, especially with regard to the collection, preparation and arrangement of the statistics.
SUMMARY OF RECOMMENDATIONS
1. That no more trained nurses can be obtained for military hospitals from institutions managed by the Public Health, Lunacy, or Poor Law Authorities, with the exception of the institutions recognized by the Local Government Board as training schools, or from district nurses, school nurses, or health visitors.
2. The greatest care should be taken in the classification of cases. Small auxiliary hospitals should be restricted to the treatment of convalescent cases. No new hospital should be set up with less than 40 beds.
3. Secure all available probationers from training schools as they complete their full training.
4. Aim at a maximum proportion of 1 trained nurse to 14 beds in ordinary hospitals, and 1 to 6 beds in private hospitals for officers.
5. Appeal to private nurses, their employers and associations, to volunteer for war work, offering compensation where there is a serious financial loss, and securing a return of the nurses to their former position at the close of the war.
6. Ask the Dominions if they con provide an additional number of trained nurses, but abstain from recruiting in the United States or other foreign countries.
7. In a case of emergency employ probationers [including V.A.D. members] as nurses under a sister where they are approved by the matron-in-charge.
8. Increase the staff of all military hospitals, so as to ensure regular leave and more relaxation where required.
9. Give a bonus for every six months of service in military hospitals, with an increment of £1 for each period of six months after the first – to be paid on termination of service.
10. Provide better pensions in cases of permanent breakdown due to war service.
For Trained and Untrained Nurses
11. Provide transport in covered conveyance where nurses have to live at a distance from the hospitals where they work, and in camp hospitals.
12. Insist on better accommodation for nurses where it is now inadequate. Provide a matron-inspector to look into the conditions of all war hospitals.
13. Promise recognition of satisfactory service for all nurses in all hospitals receiving sick and wounded soldiers.
14. Provide in all cases travelling expenses at reduced fares.
For Untrained Nurses
15. Provide cost of medical examination for all probationers, including V.A.D. members.
16. Relieve them of expense as regards uniform.
17. Furnish additional allowance where required for necessary expenses of members in V.A.D. Hospitals.
18. Grade V.A.D. members so as to distinguish those who have had 13 months of approved service.
19. Establish hostels where V.A.D. members may reside and hear lectures, and from which they can go for daily training in civil hospitals.
20. Appoint a matron-inspector of V.A.D. Auxiliary and Private Hospitals for each Command in the United Kingdom, whose reports should be submitted through the Commands to the War Office for final action.
21. Make arrangements that the trained matron should be in charge of the nursing staff in V.A.D. Auxiliary Hospitals.
22. Bring all the nursing authorities into touch by establishment of one central committee to act as a clearing house during war time.
23. Encourage the making of a census of all women suitable for nursing, and willing to undertake it for the period of the war.