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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 Warwick union workhouse.

WARWICK.

The workhouse, standing on the outskirts of the town, is a red brick building dating from the year 1838; the infirmary buildings opposite, separated from the house by the public road, were erected a few years later. The situation is open on all sides, the Board having many acres under cultivation. It gave us great pleasure to be met by two lady guardians (the Mayoress of Leamington and Mrs. Burgess) and by Mr. Bailey, the Chairman of the House Committee; the latter had a store of useful statistical information which he kindly placed at our disposal.

The infirmary being our special concern, we asked permission to visit first that part of the buildings. Its plan is a compact parallelogram, the administration block being in the middle, with the male and female wards on either side, the part used for the women being rather the larger of the two; it is a three-storeyed building, and has accommodation for 96 patients, the average number of beds occupied being 80. The space is cramped, the landings being small, and the staircases, which are principally of stone, confined.

On the ground floor on the men's side there was a small day room, and opening out of it a ward for 8 beds, one of which was occupied, the remainder of the patients being in the day room, or seated round the fire in the ward. On the next floor was a large ward for 12 beds, 3 of which were occupied, the rest of the patients being up. Above, again, were 2 smaller wards, with 6 and 5 beds respectively. The arrangement of the wards is throughout the same. There are windows on both sides, and the beds are between the windows; a large deal table in the middle, with benches and armchairs for those who are up; little tables between some of the beds, and one or two commodes for night use. We were sorry to see the chamber utensil under each bed; this betokens some want of sanitary care.

The wall surfaces are of brick, painted with silicate in two colours. The windows are rather small, and set high up in the wall, so that the patients cannot see out of them as they lie in bed. The ventilation is chiefly by the windows, the amount of opening being regulated by means of a rack; there are, besides, ventilators in the cornice. The wards are warmed by open fires and lighted by gas. A few of the bed-steads were of modern pattern and supplied with a pull; the majority were of the old style: almost all of fair width. The bedding was flock, hair, or "oat fly"; in no case were mattresses in use. Over the laths was a very thick fibre mat, but the matron considers that this is not cleanly; as they wear out she is not having them replaced. Water mattresses and cushions are supplied for such cases as require them. The quilts are red check, of the old-fashioned heavy cotton make; they might with advantage follow the fibre mats. We were struck with the lack of cupboards, and wondered how and where the necessary appliances for ward work would be kept.

On the intermediate landings on each floor are isolation wards, small rooms which have been used for itch or lock cases, or for any very offensive case. We were glad to see that the "dirty cases" were not herded together in some back ward, but were treated among the other patients; the nurse told us that she found that plan answer best. The medical officer (Mr. Roger Bullock) informed, us that he very seldom had any lock patients under his care. The infectious patients are removed to the sanitary hospital.

The arrangement of the wards is similar on the women's side, except that the day room is now used by the nurses for their meals, and that extra wards are provided for the women by the use of an addition built on to this wing for a children's hospital, now occupied in great part by adult female patients. In this addition we found larger windows and smooth wall surfaces, sure indications of a more modern construction. One ground-floor ward was used as a children's ward, and in a room at the top were some girls isolated for ophthalmia. The temperature of the children's ward seemed to us decidedly too low; the fireplace appeared too small to warm the room effectually. In this same block on the ground floor was a comfortable ward of 4 beds, kept, so the chairman told us, for the more respectable women.

The infectious hospital, no longer used as such, is supplementary to the infirmary. It is a detached building, connected with the infirmary by a glazed corridor; there are two wards divided by a kitchen, each holding 10 beds. These wards are lofty, and have large windows facing each other, smooth walls, and ventilators in the ceilings. They were occupied by female patients. There are open fires, and, besides these, two hot water pipes. the supply being heated in a small boiler behind the ward fires. Even so the temperature of the middle of the ward was only a little over 50° (there was a hard frost outside). The glazed corridor is a favourite place in the summer; it is supplied with seats, and makes a good recreation place; the patients call it "paradise."

There were about twenty patients in all in bed, the majority of these being women. There were no cases of acute illness at the time of our visit; the nurse said that she was not taking any temperatures just then. We learned from the doctor that as a rule the severe cases were treated at the Leamington Hospital, whither all cases requiring operative treatment were removed; the guardians subscribe to the hospital. This leaves the cases of chronic ailment and infirmity to be treated in the workhouse infirmary; such as we saw would come under that category: ulcerated legs, paralysis, phthisis, asthma, heart disease, rheumatism, bladder trouble, hernia, and senility. The advanced age of the patients was a marked feature; the chairman told us that the average age of all the old people in the house and infirmary was 75 years, and, though so large a proportion were sitting up, some were very helpless.

There is no classification of the patients. The nurse informed us that she endeavoured to place the more serious cases on the first floor, which is near her room. We saw imbeciles, feeble-minded, and epileptics in the wards as well as at work all over the house; there is no certified department as the lunatics are at once removed to the county asylum. A boy of about 8 or 9 was confined to the children's ward as he was idiotic.

The lying-in ward is in the house on the first floor in the middle block. It consists of one room holding four beds. It has no special appliance, such as a water supply, sink, and bath for its use. Above this room is another where the pregnant women sleep, awaiting their time. The number of confinements is small, averaging ten or twelve in the year, but should there be an increase in the number there would still be no separate labour ward available. The infirmary nurse is the midwife. There is a bell from the lying-in ward to the matron's quarters.

We found two nurses engaged in the infirmary, both of whom had been trained, the head nurse at Sheffield and Liverpool infirmaries; the assistant nurse at the Fulham Infirmary. In each ward there is a wardsman or woman, and these latter were kept to these duties as far as possible. The building is an awkward one from the nursing point of view; the wards are mostly small, and scattered up and down.

There is no night nurse, and only in the event of a serious case does anyone, even a pauper, sit up. There are bells from the wards to the nurses' quarters. In conversation with the nurse the fact was elicited that the atmosphere of the wards in the early morning is anything but sweet; and it must be so, as the helpless patients cannot be properly cleansed nor the vessels promptly emptied. The chairman said that this matter of night nursing had been a vexed question on the Board, and that the feeling at present was that the employment of a trained nurse at night would not insure prompt attention to the helpless, and that the inmates were more likely to prefer one of themselves as an attendant. These arguments are not new, nor are they convincing; the able-bodied pauper as a nurse is at best an unreliable and irresponsible servant, without capacity or dexterity, not to mention experience and tenderness. It is easy to guess the sort of sleepy response which the appeal for assistance to a companion of the ward receives in nine cases out of ten. Two competent nurses, not necessarily fully trained, would not be too many to ensure proper attention to the helpless.

The guardians have thoughtfully devised doors of communication on each floor between the divisions, so that the nurses at night or in bad weather can pass from the one to the; other without going out-of-doors. These same doors are also intended for use in case of fire, and are supplied with a key in a glazed case, with its attendant mallet; the fire appliances all over the building were well in evidence, and appeared to be in order.

There is a porcelain bath on the ground floor on the male and female sides, with a supply of hot and cold water, and adjacent a watercloset of modern construction, quite clean and sweet. With regard to this latter, a contrivance of the nature of arms or a pull from the ceiling is required to give the infirm the necessary leverage in rising. The difficulty suggested is not an imaginary one. There is a third fixed bath on the top floor of the children's hospital. On each landing we saw hot and cold taps discharging over a small triangular trough, and also a watercloset. The water is heated in the infirmary scullery, where also there is a copper giving a supplementary supply. We learned from the nurse that the supply of hot water was constant and adequate. There are no slop sinks, and we only saw the one sink for washing up in the scullery. The drainage WAS overhauled five years ago, when the new fittings were supplied.

The infirmary laundry adjoins the infirmary, and the nurse has the control of it. The supply of linen is distinct from that for the house, and the nurse said that all soiled linen was sent at once into the laundry. The nursery is in the house, opening out of the day room for the able-bodied women. The floor, like that of all the rooms in the house, is of brick, but there was a good piece of matting in front of the fire. The three infants in the nursery all looked in good case; they were in charge of pauper women. We did not like the aspect of the room, which was sunless and dreary, and there was the usual absence of toys and cheerfulness.

The dietary has just been revised. It is designed to make the food more varied by having meat pies or puddings, jam or marmalade, alternating with butter, tea or cocoa for the sick; and an attempt is made to check the waste of bread in the children's department. The bread is baked on the premises. All the diets are cooked in the house kitchen, and sent over to the infirmary in large covered wooden boxes; the cooking is done by the inmates.

RECOMMENDATIONS.

It struck us that this infirmary was a difficult one to work and supervise. Certainly more nurses are needed; if two were added for the night they might lighten the work of the day staff in the mornings, when the whole staff could work together at making the beds and the patients' toilet. This would render increased accommodation necessary in the nurses' quarters, when a recreation room might be added with advantage. There is a lack of day rooms for the patients; in any alterations of structure these would be a valuable addition. The children's ward requires a larger fireplace, and would be better placed on the first floor. More cupboards and a small surgery would add to the efficiency of the nursing and the comfort of the nurses. The lying-in ward wants remodelling: it should be placed in the infirmary department or adjacent to it; a labour ward is a necessity, and a bathroom and all sanitary appliances should be added. We would further suggest that some alteration be made in the nursery department; that a boarded room be selected for the purpose, with a sunny aspect and separate offices; a responsible officer with leisure to attend to the infants to be placed in charge of them. We would also suggest the addition of slop sinks and other sinks about the infirmary, to facilitate the emptying of slops and the washing-up of crockery for service.

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