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BMJ Reports on the Nursing and Administration of Provincial Workhouses and Infirmaries, 1894-5.

In 1894-5, the British Medical Journal — as part of a campaign to improve the nursing and medical facilities in workhouse infirmaries — conducted site visits to around fifty workhouses in England and Wales. Below are extracts from their report on the Chester union workhouse.

CHESTER.

The workhouse is about a mile outside the city, the infirmary buildings standing behind the main block; these are in three parallel blocks connected by wide bridges. The latter form a pleasant airing ground for the patients, and comfortable benches are placed on them. One block is set apart for the imbeciles and harmless lunatics; one block accommodates the medical cases, the infirm patients, and the lying-in wards; and the third block has the surgical cases, some infirm patients, and the children. The male and female inmates are thus in each block, and a trained nurse is in charge of each block. The infirmary is returned as accommodating 247 patients, but this includes the imbecile block; the average is about 80 in each block, more or less. The blocks are entirely apart, there being no means of communication except by the bridges aforementioned.

The system of nursing is a mixture of the trained nurse with pauper help; both the nurses whom we saw had received hospital training, but they could not attend upon 80 or more patients; hence the pauper inmate is requisitioned to supplement them, and the style of the work bore out that system. At night there is one trained nurse for the two sick blocks, and in each block there is a male and female attendant besides; these latter are paupers. We lay stress on these points, bearing in mind that just recently an inquest was held on a pauper who died under circumstances that aroused suspicion that his death had been caused by the rough treatment which he had received at the hands of his ward attendant. The jury returned a verdict of manslaughter. With that verdict we have nothing to do; but we wish to emphasise the criticism of the coroner, who asked, "Is there no person here to take the night nurse's place when a person is dying in another ward?" and the recommendation of the jury that "there should be an assistant night nurse in the hospital in case of emergency." When the nurse is in the one block she is as much away from the supervision of the other block as though she were in another street, and in her absence and before she could be fetched (for there are no communicating bells) there is time for any such tragedies to occur, the patients being practically in the hands of the inmates. In plain terms, the night nurse has to see after 160 patients in separate blocks. Pauper help is of necessity largely employed in this infirmary. We saw the wardsman or woman in each ward; from the evidence given at the inquest these inmates wash the patients "in a bowl, whilst he or she is seated on a chair at the bedside." So lax a system admits of accidents, and it depends entirely on the vigilance of the nurse to discover any mishaps which may have befallen the patients in her absence, unless attention is called to the matter by some courageous inmate.

The wards are small, the largest containing eleven beds; the others have six and four beds in them severally; this arrangement applies to both blocks. The wards are comfortable and homelike in appearance, the bedsteads of the full width, and the bedding is long straw, well filled, except where the nature of the case requires a water mattress, which the matron informed us was then supplied. The patients are classified as medical and surgical, the dirty cases being distributed among the other patients. The lock and itch patients are in a small separate block containing six beds for males and the same for the females. The master is responsible for the male patients, whilst the matron visits the female side of this isolation block. There is a labour ward having two beds; it struck us that the bed used as the labour bed was inconveniently small for its work. The women are convalesced in the larger ward. In the children's ward, which is on the ground floor, we found nice modern cots, and wool mattresses; these are a gift from a guardian who takes interest in the little ones. The ward looked cheerful and comfortable; it holds eleven cots, and has its separate bathroom and offices. There were very few children in at the time of our visit, and no severe case. A pauper is in charge of this ward.

The patients, of whom only a few were in bed, included a severe case of cancer of the face — this was dressed with sal alembroth wool and gauze — it was most offensive and required isolation; a woman in an advanced stage of internal cancer; several cases of ulcerated legs; a man recovering from pneumonia; some cases of paralysis and of senile debility. We saw a hale old body whose bedcard recorded the age of 101; she was in full possession of her faculties, and was proud of her great age. The itch ward on the female side was given up to some children with measles; these were in the care of their mothers, and we could not ascertain that they received any care from the nurses; we saw one child on whom the rash was fully out, dressed, and in its mother's arms, the lower part of its body was exposed to any chill, and the ward was not very warm though the day itself was so. That child was not being nursed in the hospital sense of the word, and no precautions were being taken to keep it in one temperature. When the doctor is required in the night a pauper is sent to the master, and he sends to call the porter, who is then sent off to the doctor, who lives nearly two miles from the infirmary.

The sanitary appliances are not up to date; the baths are movable, and stand on the landings, where they are used behind screens. Hot and cold water is laid on for ward use, but the bath water is heated by geysers, which the matron informed us were quite efficient. The closets are also on the landings, a step or two down, and at a little distance from the wards, so that commodes are in use at night. There seemed to be a sufficient supply of water. The bath for the children's ward is a fixed one. Gulleys are provided for the emptying of the large baths. There is only one day room, and that is on the men's side; the men are allowed to smoke in the wards, or on the bridges. The airing courts are of the usual back-yard style, but the bridges have to a certain extent superseded them.

RECOMMENDATIONS.

There is much in the structure of the infirmary that might be improved. The wards are crowded, and there is no ward for the separation of an offensive case or patient requiring isolation; day rooms are needed to relieve the wards of the more convalescent patients; bath rooms with improved closet accommodation are a necessity, especially in the lock and itch wards. Then the nursing staff is lamentably weak, we might almost say dangerously so, in the light of the late inquest. We would suggest that the pauper nurses be withdrawn, and that more fully-trained nurses be engaged, who should be assisted by a few probationers; that one nurse at the least be on duty at night in each block, and that the wards be placed in communication with each other, and with the master's quarters by means of a telephone or bells, and that a telephone be laid on to the doctor's house; that the isolation block should be placed under the care of the trained nurses, and that the whole infirmary be made into a separate department under a trained superintendent.


The BMJ subsequently published its response to a letter from the Chester workhouse medical officer:

CHESTER: A CORRECTION.

We have received a letter from the medical officer of the Chester Workhouse (Dr. Archer), pointing out a few inaccuracies in the report of our Commissioner on that infirmary. We are as anxious as himself that there should be no exaggeration in the reports that we are publishing, therefore we give the sum of his letter. He first states that the number of patients reported as being under the charge of each day nurse is in excess of the facts; but as the report refers to the number of beds for which the infirmary is licensed, this may account for the discrepancy. The separate block for the lock and itch patients contains "four beds in the male lock, six in the male itch, five in the female lock, ten in the female itch." Dr. Archer traverses the statement that "a pauper is in charge of the children's ward," and states that" although a pauper sleeps in the ward with the children and helps to look after them, the ward is on the same floor as the nurse's room,' this seems to us a question of degree, as it is evident that the nurse must rely on the pauper when her duties call her to other parts of the building, and for twelve or more hours the pauper is in sole charge. Our Commissioner commented upon the need of improved closet and bathroom accommodation," especially in the lock and itch wards." The medical officer states that there is a separate closet. and bathroom for each of these wards; we apologise for the mistake, and are glad to find that the need has already been met. With regard to means of communication with himself at night, this again is a question of degree, though every available means is taken by the master to bring the doctor as quickly as possible. Still we say that anything short of telephonic communication is insufficient. We are obliged to Dr. Archer for his comments, especially as they serve to accentuate the main facts of the case, which it was the duty of our Commissioner to ascertain.


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