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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 Nottingham union workhouse.

NOTTINGHAM.

The workhouse stands in a crowded part of the town, on rising ground with open space at the back, but shut in by buildings in front. It is one of the older houses, the greater part being over fifty years old, but the wards used for the surgical patients date from twenty years later. The house is licensed for 876 inmates, but at the time of our visit there were over 1,000 on the books.

The medical officer (Dr. Ashwell) and some of the guardians kindly accompanied us round the building, and the courteous officials of the house gave us every facility for making our inspection.

It is difficult to give the reader a clear idea of the hospital, as the sick quarters are simply wards in the body of the house, and formed at one time part of the quarters for the able-bodied; the overflow of the sick are in a separate block to the front of the building, at some distance from the hospital. The house is a long building, consisting of two extended wings with the administration block in the middle, and it rises to a height of four storeys. The wings are divided in their length by long narrow passages, having wards or dormitories on either hand; a narrow stone stair leads from the passages to the upper storeys. Besides these staircases, one on either side of the administration block, there are enclosed stone stairs in some of the wards, leading to the floor above; they appeared to serve as a depository for useless lumber.

The sick are nursed in those dormitories the able-bodied being now lodged in miscellaneous low buildings to the front of the house. On the male side there are fourteen wards, holding at the time of our visit 210 patients. Each ward has nominally 14 beds, but, when necessary, more beds are put in, as on this occasion. The wards looked over full, and, being low pitched, are deficient in cubic space. The windows are on one side only, the upper half being swung on a pivot for ventilation. There are besides small grated openings in the cornice, but these appeared to be choked with the dust of ages. In each ward was a fireplace, a few arm chairs, and straight chairs, a long deal table, commodes, stools, and one or more screens. The floors are either of paving stone or cement; a linoleum path is laid down each ward, and we noticed. in a few cases only, a strip of carpet at the bedside. The surface of the brick walls is painted a light colour; a T gaslight hangs from the middle of the ceiling. This description applies to all the wards on both male and female sides, with the exception of the old women's ward, a spacious room on the ground floor, holding 22 beds. The appearance of this ward was as bright and cheerful as flowers and pictures could make it, though it was deficient in windows. It is reserved for cases of infirmity and old age among the women; though none of these are acutely ill, nearly all were in bed. It is really the only suitable ward in the building.

The beds are of the old pattern, iron laths, low and of good width; no pulls except in rare instances. The bedding is mostly flock; there are a few spring beds and a liberal supply of water mattresses. The need for these results from using flock mattresses, which are most unsuitable for the sick and infirm. Only two blankets were allowed to each bed, and, as both these were required for warmth, in very few cases was, there any blanket under the patient.

Classification obtains to a very moderate extent; there is a separate department for the idiots and feeble minded, and the surgical and lock cases are in the block at the front of the building, but the male infirm and acute cases are mixed together in the wards. We noticed some very severe cases among the medical patients: a bad case of typhoid fever, chest complaints in all stages, heart disease, frostbite, rheumatism, phthisis, all cases that would be treated in a hospital, besides the usual type of workhouse patients. In an attic ward we saw a man who had broken his back fourteen years ago when he was working as a navvy on the line. He was in good case and contentedly employed himself in doing fancy work. There are no children's wards, as there is an infirmary ward at the schools.

The surgical block includes the nursery department, the male and female surgical wards, and the lock cases — 158 beds in all. It is a more modern structure; the wards are loftier, the surface of the walls is smooth, the larger windows have sash openings, and are placed lower in the wall. To reach this building from the other sick wards we left the main entrance, and passed along a covered way and down some steps into a court. The lock patients are in the top storey; there were two female patients in a ward of 8 beds. There are no separate offices for these patients on the female side. but the male lock ward, also on the top floor, has a separate lavatory. The wards on the female side are large but crowded; on the male side the wards are smaller. There are no airing courts for this block. The medical officer informed us that he did all necessary' operations. There were cases of ulcerated legs, bladder cases, cancer, lupus, and strumous abscesses.

The lying-in ward is in the hospital part of the house on the first floor. It consists of one ward of 8 beds; a small apace, divided from the rest by a thin partition, forms a labour ward. Here we found an old wooden bedstead with a flock bed on it, which was, we were told, taking the place of the mattress which had gone to be cleaned. The bed was amply provided with appropriate sheets. This enclosure is, of course, not sound proof. but is otherwise private. There was one woman and her babe. The confinements are from 70 to 80 a year. The senior nurse is the midwife. One closet at the end of a passage is kept for the use of the lying-in ward.

The idiots are lodged in distinct wards, but close to the hospital quarters. There are 120 beds for male and female patients of this class. We saw the patients gathered in the day rooms as it was the dinner hour. We noticed with pleasure a mincing machine handy for the attendant to mince the food of any helpless patient. Their dormitories are similar to those of the sick, but the beds are furnished with side planks and other contrivances for the restraint of the restless. The airing courts for this department are good, but the day rooms appeared to be too small to admit of the amusement of the inmates. At each side there is a padded room off the attendant's room. The inmates are certified, and are attended by trained attendants, two on the male side and two on the female. Altogether the department contrasted favourably with the sick quarters.

On the male side are two trained male nurses, who attend to the 210 patients in the hospital wards, and the male patients in the surgical block. Under these circumstances pauper help is largely used in nursing the sick. On the female side there are three trained nurses, including the midwife, who has charge of some of the general wards; thus there are two nurses for the 160 female patients in the hospital, and one in the surgical block. A staff of inmates watch in the wards during the night; these sleep during the day in the body of the house, and one night nurse is on duty in each wing. There are no means of communication between the wards and the master's lodge but by messenger, but the master's quarters are connected by telephone with the doctor's house, which is close by. Our brief inspection was yet sufficient to show that the nursing was carried on under great difficulties, very crowded wards, a lack of appliances, an insufficient staff, supplemented by pauper help, no day rooms. It is greatly to the credit of the officers that any results which can be called satisfactory are obtained. The quarters provided for the nurses are cramped and uncomfortable; they have no mess room or recreation room, and their bedrooms are too close to their work. There appears to be at present no room for an increased staff of nurses, even if the Board were convinced of the desirability of employing them.

Isolation is provided for by two iron huts placed in one of the courts adjacent to the main building. These huts are self-contained, and are used for the nursing of cases of measles or whooping-cough from the schools. Fever and small-pox are taken to the rural sanitary hospital. Nurses are engaged from the town when the huts are required; they were empty at the time of our visit. The last use to which they had been put was to accommodate the overflow of able-bodied men from the house. There are no small wards in the hospital for the keeping apart of an objectionable patient.

There are several closets in the hospital, but not always conveniently placed; some are on landings between the floors, some at the end of the long passages; they are well flushed, but of the old make, small, and the fittings enclosed in wood. Near the closets are the washing-up sinks, few in number, and also some fixed basins for the use of those inmates who are up. The bath rooms opened in most instances off the wards. The whole of the sanitary appliances for the old women's ward are in a lobby leading out of the ward; the lobby was used as a kind of scullery or pantry, and we were surprised to see the bread intended for the dinner lying in very close proximity to the w.c., which opens from this lobby. On inquiry we found that there was no satisfactory provision for keeping the food for the wards. In each ward were commodes; in some we saw chambers under the beds. Slippers and dressing gowns are provided for the inmates. The water is heated by a central boiler.

The nursery is placed, as before mentioned, in the surgical block; it occupies three storeys. The day nursery is on the second floor, and the night nurseries on the first and ground floors. The whole department is under a paid officer, and bore marks of thoughtful care on the part of the guardians. Toys, pictures, suitable chairs, and tables were provided for the little ones; proper cots for the night, boat-shaped feeding bottles, etc. We were specially pleased with the bath room, where each child had its separate towel and brush and comb on a numbered hook. a running water supply over a trough for washing, and a suitable bath, all of modern construction. The infants remain in the nursery until they are 5 years old, when they are drafted to the schools, a mile or more away.

The diets are cooked and weighed in the central kitchen, and distributed to the various departments. The inmates on meat diet have it boiled except on Sundays, when it is roasted. This is an old custom which dies hard; but it is not rational, and we shall be glad when the infirm in the workhouses are allowed a more varied diet. The sick are dieted by the medical officer. We noticed a very handy carriage for the diets, heated by a hot-water jacket; each ration was in a separate dish,. on a tray containing the number for the ward, the whole running on wheels. The food appeared to be well cooked, and was served hot.

The receiving wards are simply for the detention of inmates until passed by the medical officer; there is no quarantining arrangement. The boys or girls are placed apart in wards in the hospital for a fortnight before being sent to the schools. Adjacent to the receiving wards are two large storing rooms under the care of the labour master. We ascertained that the guardians have no vehicle for the removal of the sick to the workhouse; they employ the public cabs, a highly reprehensible practice unless they have the vehicle thoroughly disinfected before it leaves their hands.

RECOMMENDATIONS.

It will be gathered from the foregoing report that the only possible remedy for the present unsatisfactory state of affairs is to build a new infirmary, a course which, as we were informed, has been resolved on by the Board. As it is now ten years since the question was first mooted, we shall expect shortly to see some steps taken towards the carrying out of the resolution. We would suggest: the substitution of female for male nurses, or at least that there should be female supervision; a liberal increase of the nursing staff, with the complete abolition of pauper nursing; wards for nursing the sick children apart from the school; the provision of an ambulance for the removal of the sick; and a more varied diet for the infirm. There appeared to be room for improvement in the imbecile department; more might be done for the patients in the way of employment and recreation, and in the dormitories there should be more means of isolating the fit cases and the unruly.

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