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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 Tonbridge union workhouse.

TONBRIDGE UNION.

This workhouse is situated on a hill, commanding a view, that a millionaire might envy, over some of the loveliest scenery in Kent, which looked its best in the bright sunshine as we reached the house after a drive of two and a-half miles from Tunbridge Wells. The buildings, standing in extensive grounds, include the workhouse proper, erected sixty years ago, with the prison-like windows, solid walls, and small courts of that period; the old hospital, a four-square building apart from the house; the modern red-brick infirmary; and the schools block.

The medical officer, Dr. Walter Malden, was kindly awaiting us, and under his escort, and accompanied by the master, we turned our steps to the sick department. There is accommodation for 230 sick and infirm, who are distributed in the old hospital, the infirmary proper and the isolation block, for already the rapid growth of the population in the neighbourhood is taxing the resources of the house to the uttermost.

The old hospital, containing 80 beds, is now used exclusively for the infirm male patients; it represented the whole of the sick department until the year 1890, when the new infirmary was opened. The building comprises a ground floor with two storeys above. The door is in the middle, opening on to the staircase, and giving access to the wards on either hand. On the ground floor are two day rooms leading into wards; these day rooms are small, and insufficient to accommodate all the patients who are up. In the summer this would not affect the comfort of the inmates, as they have free access to the extensive grounds; but in the winter the majority of the old men must needs live and take their meals. as well as sleep, in the wards. The wards are square or oblong, holding from 8 to 12 beds; the smooth-surfaced walls are colour-washed or painted. The windows are small, and divided into two by a. heavy moulding; they are set rather high and open sashwise. There are also hopper openings below the cornice for additional ventilation. The wards are heated by open fireplaces and lit by gas. The bedsteads are ranged along the walls; there is a table in the middle; armchairs, a locker, a commode, sometimes a piece of matting, and a few pictures completing the furniture of the wards. There was an air of comfort in the place. Most of these patients were up, as this building is intended for those who can be dressed; the few whom we saw in bed were there for some slight precautionary reason.

On each landing there is a bath room and lavatory; the former in the old style, a metal bath with unprotected sharp edges, with hot and cold water laid on from the hospital kitchen; the latter modernised, with a good flush and glazed brick risers, all quite clean and serviceable. On the intermediate landings are two small wards, in which a noisy or troublesome patient may be kept apart. These were empty at the time of our visit.

The bedding is various, flock or hair on a straw paillasse, and the bedsteads, though of good width, are low and of the old pattern. As we understood that changes were in contemplation for this block, it is probable that the furniture will be modified. This part of the house furnishes a good example of the transition period, when public opinion was beginning to realise that the sick pauper needed other treatment than that of the workhouse as it was constituted under the Act of 1834.

The new infirmary block gives expression to the modern opinion of the requirements of a hospital for the sick, even if they happen to be paupers. It stands a little apart from the old hospital. The entrance is under an archway which gives access to the grounds and the schools beyond; the male and female wards opening from either side of the archway. We entered first a spacious hall. on the female side, out of which on the left is a day room, leading into a ward of 12 beds, from which a door communicates with the lavatory through an intercepting lobby. Out of the same hall are the kitchen, bath room, head nurse's sitting room, and staircase to next floor; this plan is followed throughout the building.

The wards are oblong, having windows on either side, with bedsteads placed between; open fireplaces, two in each ward; smooth painted wall surface, coloured matting down the middle of the ward, and pictures, give a cheerful appearance. We also noticed a good supply of arm chairs, in which the patients were sitting round the fire. This was the arrangement through the general wards. In the corners are "hit-or-miss" ventilators, which are supplementary to the sash windows. Nevertheless there was a sense of stuffiness in all the wards, more or less; as this cannot be attributed to the machinery, which was adequate, the cause must be sought elsewhere. The bedsteads are new and wide, some of them furnished with pulls; the bedding consists of the straw paillasse and hair mattress, and each bed has an allowance of four blankets. There were some screens prettily covered with chintz; the screens themselves might have been lighter with advantage, so as to be readily carried wherever they were required for privacy.

On the female side there are 65 beds, including those in the lying-in wards, which are placed in the top storey, and comprise the labour and convalescent wards, and a larger ward for such pregnant women as require to be kept under observation at night. There is a bath room on the landing, and here also is the bedroom of the head nurse, who acts as midwife. In the "waiting" ward we found children under seven, infirmary patients, there being no children's department — a great omission; for it cannot be desirable to keep the children carefully apart in health. and then allow them to mix with the loose women who frequent the maternity department of a workhouse. Otherwise we have nothing but praise for this part of the building.

The male infirmary is on the same plan as the female; it has 60 beds on two floors. The men, as they are fit for it, are drafted to the old hospital, so that we found the work heavier on the male side, the cases more serious, the convalescents in smaller proportion. There are four day rooms in this block, but the meals are served in the wards.

The isolation hospital, miscalled the infectious hospital, is a detached building communicating with the main portion by a long corridor from the female block. It has 33 beds in various small wards, and was at first intended for infectious complaints, but as these are now sent to the rural sanitary hospital, it is reserved for lock cases, offensive patients, or for measles and whooping-cough among the children, the latter complaint being, at the time of our visit, prevalent in the schools. The block is complete in itself, and is planned to receive male and female patients, and a portion can be locked off entirely if required for quarantining purposes. We found patients there with whooping-cough, some venereal cases. and the wet cases. The wards are smaller, but quite as well found as in the main building. The corridor is sheltered and sunny, making an excellent resort for the inmates.

An overlooked detail in the quarantining system is teat there is no intermediate ward between the receiving wards and the house, for the reception of the fresh arrivals, wherein they can spend the fortnight under observation before being passed by the medical officer to the department to which they are assigned.

There is no system of classification among the patients; the medical and surgical cases are together, and we also saw the feeble-minded among the patients. The medical officer informed us that the greater number of the idiots are in the infirmary department for their safer custody. There are, however, the small wards, where a noisy or an unruly patient can be placed, or for the isolation of the severe cases of fits. As already noted there is no children's ward.

We have been describing a well-planned and well appointed infirmary, but when we look for the human machinery to develop its resources we meet with disappointment; the nursing does not keep pace with the structure. There are no trained nurses by day; the present head nurse has been six years in her post, and we are sure, gives of her best, but however willing her service, it cannot be as efficient as skilled service. The staff consists of the head nurse and two assistants in each block, one nurse in the old hospital and one in the isolation hospital by day: there is only one night nurse for all the buildings, but another is shortly to be appointed. None of these are fully trained nurses except the night nurse, who is only temporarily engaged. In each ward there is a pauper help.

The nature of the cases demands skilled nursing; there are the usual bedridden and helpless patients. and we were informed that many serious cases of heart disease are often to be found in the wards, as also cases of phthisis, rheumatism, paralysis, and ulcerated legs. Moreover, the doctor undertakes any surgical operation which he may consider necessary, and has performed major operations in the infirmary. At night, even though the nurse be trained, she cannot nurse, for her work is very scattered, and, however zealous, she cannot be in more than one place at a time.

By a strange oversight, no provision for a nursing staff was made in the plans, so that the makeshift quarters occupied by the nurses are cramped and insufficient; their only mess room is one of the ward kitchens, and they have no recreation room. The night nurse is lodged close to the isolation wards. The Board is alive to these deficiencies, and is endeavouring to make things more comfortable for the staff.

The nursery is in the house, a new erection just added to the old building; the day nursery is on the ground floor, and the night nursery above with a room adjoining it for the mothers whose infants are still at the breast. The whole department is under a trustworthy paid officer, who is responsible for the infants and for the discipline of the mothers when with their children. It was the dinner hour, and several of the mothers were present in the nursery; the other children not in arms formed a happy little group round a low table. They remain here till they are 5 years old, when they pass into the schools. The nursery was bright and cheerful with toys and pictures, and the little ones looked well cared for. We were glad to see the old-fashioned boat feeding bottle in use. In the night nursery each child has its own cot.

The kitchen offices are in the hands of the builder, the whole of that part being in course of reconstruction. We were given to understand that when the alterations are complete, improved methods of cooking and serving would be introduced. At present the rations are served to the infirmary in the bulk, being carved and weighed by the nurses; this renders it necessary for the whole of the small staff to be in the kitchens instead of feeding the sick. As we went round we saw the paupers feeding each other, a practice much to be deprecated. We were struck by the monotony of the meat diet, which is always mutton. Doubtless with the remodelling of the range will come the recasting of the dietary tables, and also the method of carriage; at present the diets are carried in open wooden trays in a covered barrow.

The hospital linen is all passed through the one laundry, and is collected daily; offensive linen is sent away at once to a special tank, through which it passes before reaching the laundry. No particular receptacle for soiled linen was in use in the sick department. In this connection we may also note the absence of lockers or cupboards for the patients' clothing and possessions. We saw clothing lying about, under beds, on tables and chairs, giving an air of untidiness to the wards. Nor was there any provision for the storage of nursing appliances adjacent to each ward. There is a complete surgery on the ground floor, with its locked cupboard for poisons, and store of drugs (provided by the guardians), for the use of the medical officer.

The sanitary appliances are of modern construction; the waterclosets are at the far ends of the wards, separated by an intercepting lobby; there is a sink for emptying pails and cleaning vessels, but all bed vessels are emptied at the closet. We always marvel at the absence of the handy slop sink. Here also are stored the vessels, though we were surprised to see chambers under some beds in the infirmary. There are also commodes in the wards, a result we suppose of the insufficient night staff. We were informed that slippers were provided if the patients chose to make use of them, and we would suggest that one or more dressing gowns might be provided in each ward. The bathrooms, one for each ward, open off the wide landings; they are fitted with porcelain baths, set out from the wall and provided with hot and cold water.

Fire escapes are supplied to every part of the old hospital and infirmary, and the whole building is in telephonic communication with the head of each department, with the master's office, and with the doctor's house, a quarter of a mile away. The master has drilled his male officers and the more intelligent of his inmates into a fire brigade, and we had the pleasure of seeing these assembled, properly equipped, with engine, hose cart, and stretcher, within three minutes of the alarm being given.

RECOMMENDATIONS.

We have noted minor details as they occurred to us, but there are a few points, affecting the efficiency of the whole, to which we would more especially draw the attention of the guardians. First, the nursing question. A large sum has been expended on the buildings, but the full value of that outlay cannot be secured whilst the administration is in the hands of an unskilled staff. In the next place, wards for the children of both sexes under 12 years of age should be provided. Thirdly, there is need of a quarantine department for the fresh arrivals. The alteration and increase in the nursing staff would also render additional quarters for the nurses necessary; but as these really ought to have found a place in the plans for an infirmary department of 230 beds, this is not a difficulty which will give rise to much sympathy, while it calls loudly for a remedy.

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