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THE STATE REGISTRATION OF NURSES

I

DURING the last few months the subject of State Registration of Nurses has been much discussed, and partisans of both sides have circulated literature on the subject. In this Review there have been two excellent articles, one by Lady Helen Munro Ferguson, in February last, in favour of State registration, and one by Miss Lückes, matron of the London Hospital, against it. I will preface these few remarks by saying that I began studying the question with an open mind, but was naturally a little biassed against registration by the views of Miss Florence Nightingale, the pioneer of skilled nursing, and by the formidable list of experts which was sent me, who object apparently to any form of registration. But a careful study of the question has inclined me to believe that some form of organisation would be of enormous service, not alone to the members of the profession of nursing, but to the general public. It is the point of view of those who employ skilled nurses that I shall try and put before those who may be interested in the subject.

At present all nurses are classed' together, those who have the highest qualifications, and those who have none at all. Registration will at least eliminate the wholly untrained or imperfectly trained. The general public has no means of finding out what training, if any, the nurse has had, except by personal investigations, which are not always possible. It will be seen by a circular issued by those in favour of State registration that the census of 1901 showed that there were about 80,000 women engaged in nursing the sick in the United Kingdom. Some it must be presumed have qualified in all branches, some have nursed four years in a London hospital, some have spent a few months in a 'special' hospital or country infirmary—in fact, there is no end to the variations of so-called training; but all these women have the right to call themselves trained nurses, they adopt the usual uniform, and can be, and are, employed without discrimination by those requir ing skilled attendants. It was with great surprise I noted that Miss Lückes (who is head of one of the best, if not the best school for nursing in the United Kingdom) seemed to attach so little importance to

technical training. From the point of view I have adopted, surely the question of technical training is the whole point. Before the days of Miss Nightingale, any woman was supposed to be able to nurse an invalid.

When pain and anguish wring the brow,

A ministering angel thou.

But when medical and surgical science have made the strides they have, the absolute necessity for having skilled nursing is indisputable. Should only a good-tempered, high-charactered, nice woman be required, who could thoroughly be trusted, most establishments could provide one, either a relation or a trusted old servant who could do all that love and affection could suggest for the patient; but when a trained nurse is required, the public should surely be able to get one, and have some guarantee of her efficiency. No amount of amiability or unselfishness is of any use in the operation theatre without professional skill; the importance of technical knowledge in a nurse is increasing every day; in operations, the sterilisation of the instruments, the aseptic precautions, &c., the intelligent watching and understanding of symptoms between the visits of the doctors, are all left to the nurses. This is recognised by the larger hospitals, who are making examinations more and more a feature of hospital training. No nurse failing to pass them is certificated. I know that the following example is not considered a parallel-why, I know not-but in the case of any one employing a doctor or a lawyer who is an unregistered or even unqualified practitioner, he does so at his own risk. Why should it not be the same with nurses, and a minimum standard be registered by a Council? What the advocates of the State registration suggest would be

A GENERAL NURSING COUNCIL,

a body empowered to deal with all educational matters affecting nurses, who would define the curriculum through which every woman must pass before she can be certified as a trained nurse, settle the period of her training, and the subjects of her education. The certificate signed by the matron of the training school would testify as to a nurse's general good conduct and practical proficiency, while the lecturers upon the different subjects of the curriculum would testify that she had attended the regulation number of lectures and demonstrations on each subject. It would be the duty of the General Nursing Council to appoint examiners, hold examinations, and grant to candidates who passed those examinations a State certificate in nursing. The first result, therefore, of the appointment of such a Council would be that a system of nursing education and a minimum standard of qualification would be established throughout the United Kingdom. It would be the duty of the General Nursing Council to compile and

publish annually a register of trained nurses, and to remove from the same the name of any registered nurse who proved herself to be unworthy of trust and professional confidence. So the public would, for the first time, have some measure of protection against ignorant and inefficient persons who term themselves trained nurses, and obtain responsible work in that capacity. The nursing profession would also be protected from those members of the calling who bring discredit upon it.

I do not bind myself to this scheme in its entirety, but consider that organisation on some such lines would be a protection to the public. At present private nursing is largely exploited by untrained and unsuitable persons, and the public frequently pay the fees which fully trained nurses charge to women who are either half trained or wholly ignorant of the responsible duties they undertake to perform. Considering the importance of those duties, and that in some cases the very life of the patient may depend on the efficient and scrupulous fulfilment of medical directions, the public should certainly be able to obtain some official guarantee that the nurses they employ are proficient in their technical work, and should have some means of protection against those who without any justification assume the dress and title of a trained nurse.

It is a source of wonder to me that nurses who have embraced the career of a trained nurse, devoted themselves body and soul to their profession, made many sacrifices to receive a lengthened period of training, and who I suppose hope to reach the highest position open to nurses, should look with equanimity on the profession being crowded out by untrained and unskilled nurses, who demand the same remuneration as those who have received the best training it is possible to obtain. Those in favour of registration consider that it would be the first step towards the thorough organisation of what is surely the most important profession open to women. What incentive is there now for a woman to perfect herself professionally when trained and untrained are treated alike? As a counsel of perfection, it would no doubt be well to have grades in the profession: for instance, in the case of small ailments and certain chronic cases, a nurse with less than the minimum pass standard might be sufficient, but for dangerous and severe illnesses and complicated cases only a nurse with the highest qualifications would answer. Anyhow, the public should be able to know what type of nurse it was employing. Great stress is laid on the fact by those who object to registration, that character and general suitability would be lost sight of were registration adopted. It seems difficult to realise why this should be anticipated. Candidates for registration will have to be recommended for registration by heads of training schools. Why suppose that these will recommend 'bad' or even 'indifferent' nurses, or those unfitted by character and temperament for registration, more than they now recommend such nurses for certification?

The public anyway would be better off than they now are, as they would be sure at least of technical skill, which they are not at present. Of course it is better that personal inquiries should be made as to a nurse's character; but to whom is the employer to apply? Presumably to the matron of the hospital in which the nurse is trained. But matrons are subject to change, death, and removal, and consequently it might be impossible within a few months or years of a nurse's departure from her training school to obtain such a reference. It may also be said that there is not much time in the case of sudden and dangerous illness for personal investigations, and it would be a great advantage to know that a 'registered nurse' had had a sufficient training, and had not taken up nursing as a 'fad' or for a change of occupation.

Has not the time come when the wheat should be separated from the chaff, and the nursing profession, which is fulfilling one of the greatest works of humanity in endeavouring to heal the sick,' be organised on a really sound basis? Registration would be a beginning, and would certainly testify that a nurse was properly trained and technically fit for her duties, and that she had not been guilty of unprofessional conduct or moral fault. No such guarantee is given by hospital certificates. Personal inquiries would be just as possible under a system of registration. At the present moment there is not a sufficient number of really properly trained nurses. It is difficult to understand why so many doctors and matrons of hospitals object so strongly to registration, as it would not only be a protection to the public if, when they required technical skill, they could get it, but it would, I should hope, lead to differentiation and separation into classes and grades of the nursing profession. In the same way, if a patient is suffering from some slight ailment he sends for the doctor's assistance, but should he be suffering from serious illness he commands the services of a consulting physician, and knows who he is consulting. Were all nurses who nurse the public trained for four years at the London or any other hospital which has a good training school attached to it, perhaps registration would be unnecessary, but in view of the present state of chaotic disorganisation of the profession, I cannot help feeling registration would be of the greatest possible assistance. I trust that those who occupy responsible positions in the nursing world will, instead of adopting a non possumus attitude to every suggestion made for organisation, formulate a scheme themselves to meet the undoubted needs of the public.

THERESA LONDONDERRY.

THE STATE REGISTRATION OF NURSES

II

THE State Registration of Nurses is not, and can never be, a panacea for all the real or imaginary grievances brought against or held by nurses, and its advocates do not arrogate to it any such impossible or ridiculous position. It is merely recommended as an act of justice to fully trained women, and as a means in some degree of mitigating the evils which most undoubtedly do exist.

According to the last census, 80,000 women in the United Kingdom described themselves as sick nurses. Probably not more than a quarter of these are fully trained—that is, hold a certificate of three years' work in the wards of an hospital. By what right, then, do the vast majority of these women call themselves sick nurses? Some merely to purchase a uniform for indoor and outdoor wear, being careful to see that as long a veil as possible is attached to the bonnet; or they may go to a Maternity Home, and have three months' work as Monthly Nurses, after which they do general private nursing; or they may enter a Private Nursing Home of eight to ten beds, where probationers are taught to nurse, at the expense of patients, who pay from 61. 68. to 10l. 108. a week; they may become Assistant Nurses in a Fever Hospital, after a year's work in which they do general private nursing, taking a case of appendicitis as readily as one of scarlet fever; or they may become a Cottage Nurse, having had six months' training under a superintendent; they fulfil their engagement as speedily as possible, and gladly enter the ranks of private nurses, where more money is to be made. These are some of the many methods of becoming a nurse, and, in addition to those more irregular paths, there are many general hospitals, where the probationers are trained in the wards for one or two years, and for the remainder of the four years for which they are bound undertake private nursing for the hospital; this is an excellent and rather popular method of increasing the revenues of the hospital, but seems hardly fair to either the patient or the nurse.

Before considering the justness or advisability of State registration, it will be well to determine what amount of training a woman

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