The Training and Qualifications of Nurses and Attendants in Certified Institutions
:: F. Douglas Turner, M.B. Medical Superintendent, Royal Eastern Counties Institution, Colchester.
The Nurses Registration Act is a great step forward for those nurses who are engaged in caring for people who are ill in any way from bodily ailments. Vossi%, even perhaps probably, it is a step forward for those nurses, called by the Nursing Council Mental Nurses, who are engaged in caring for people with mental ailments or affections as distinct from those with mental defect. But 1 do not yet feel that it is in any helpful sense a step forward for those engaged m training and caring for mental defectives, although I agree that theoretically it s ou e so.
And the reason is this. The syllabus of training* for those nursing mental defectives is based, in my opinion, too much on the knowledge that is properly required of those looking after sick people generally, and too little on the knowledge that is really useful for those training and caring for mental detectives. There is a danger that the examination for the certificate, and therefore necessari y the training of everyone who wishes to take this certificate, wil e arge y lvorce from the real knowledge and training necessary for every good nurse or a en an on mental defectives. To put it shortly caring for mental defectives nowadays does not consist in the majority of cases of sick nursing or anyt ing 1 e 1 , u 1 does consist of management and teaching and training. In some ins ltu ions, 77*This syllabus may be obtained from the offices of the General Nursing Council for England ftntl Wqles, 12, York Gate, N.W.I r Post free8d. (Ed.), practically all the staff, in others, the great majority of the staff are concerned only with teaching and training the patients. You cannot expect the staff in an Institution for mental defectives to first become sick nurses and afterwards trainers of the mentally defective, any more than you expect those nursing the sick to first qualify in mental diseases. Judging, however, from the syllabus of training it would appear that the General Nursing Council do think, possibly as a matter of principle, that every registered nurse to whichever section of the register she may belong, must possess a considerable knowledge of the nursing of bodily illnesses.
It is desirable of course to have some of the staff in a Certified Institution properly qualified in nursing bodily ailments. Sick patients there will always be, but taking the whole year I do not suppose the average number of patients in bed for bodily ailments in an ordinary institution would be more than between one or two per cent of the total number resident. In addition, the greater the number of really low grade patients in an institution the greater the need for nurses skilled in caring for the body, but in most institutions the number of low grade cases will probably be small compared with the trainable cases,for Dr Tredgold has pointed out in his book that the total number of high and medium grade cases is very much larger than the number of low grade cases. Nurses for the sick will, therefore, be a small minority only, and for the greater number of the staff it is far more important that they should know how to train patients to wash and dress themselves properly, clean the crockery, be a good Guide or Scout, turn out a room, act in a play, sew on a button, make a shirt, a brush, a mat, a basket, or even weave cloth, than it is they should know how to give a rectal injection or wash out a bladder. According to the regulations a Nurse going up for her examination would have to be signed up to say she had had instruction in the latter items amongst many other similar ones, but no enquiry is made as to whether or not she can teach anyone of the former items. Yet she would almost certainly nurse for twenty years in a certified institution without even hearing of such things as bladder washing, whereas her ability to teach dancing would be constantly called for.
The chief provisions of the Nurses Registration Act and the rules made thereunder are the following, and as the wording of the rules points out the feminine gender includes the masculine, an innovation which doubtless in the future will become so general as to be taken for granted in every Act of Parliament. The Act establishes a General Nursing Council whose duty it is to form and keep a register of nurses for the sick. It is laid down that amongst others this register shall have a supplementary part containing the names of nurses trained in the nursing and care of persons suffering from mental diseases. The Council has the duty of making rules for the formation and maintenance and for regulating the conditions of admission to the register, including the conduct of the examinations which may be prescribed as a condition of admission to the register. One condition of admission is that nurses must have undergone the prescribed training in an institution approved for that purpose by the Council, but provision is made for the registration of existing nurses. The majority of the members of the Council are now elected for a term of five years by nurses on the Register at the date of election.
The Act raises the status of the nursing profession enormously, and it places it on a legal basis, akin to that of a medical man. No nurse not on the State Register will be allowed to call herself a registered nurse, or wear the prescribed uniform and badge, or place certain letters after her name, and in course of time it will necessarily and properly follow that the public will only consider those nurses as properly trained whose names appear on the register. The Council has adopted certain rules for the formation of the register, and these rules piovide a section for nurses trained in the nursing and training of feeble-minded and mentally deficient persons. Existing nurses in this section were put 011 the register up to July, 1923, provided they furnished evidence of good character and of having been for not less than three years before 1st November, 1919, bona fide engaged in the nursing and training of feeble-minded and mentally deficient persons. In July, 1925, set training and examination rules come into operation, but up to that time provision has been made for the admission to the legistei oi nurses possessing intermediate qualifications. They must furnish evidence o good character and also of adequate knowledge and experience, but there wi c no examination. The evidence of knowledge must be a certificate that the applicant has had before July, 1925, not less than three years training in t e nursing and training of feeble-minded and mentally deficient persons in an Institution for mental defectives approved by the Council for the training o these nurses or the certificate of the Medico-Psychological Association certi ying that the applicant has completed her training and passed her examination e oie July, 1925. For those already on the register for Mental Nurses, two years training only is required with mental defectives instead of three yeais as a ?vc* The fee to be paid on application is two guineas and a yearly subscription of a a crown. I have been officially informed that it is in the highest degiee un i e y that the Medico-Psychological examination will be accepted after this t ate. is, however, stated in a recent issue of the Poor Law Officers Journa t la c Minister of Health shares the view of the Board of Control that it is un esna e there should be two bodies holding examinations for mental nurses, t ic e ec ?f which would be the perpetuation of two classes of mental nurses, one r^S1^ tered, and one not registered who might yet have and prefer to have the eerti ea e ?f the Medico-Psychological Association. A conference is suggested an i seems possible therefore that there may be some arrangement, but as matters stan a present admission to the register after July, 1925, can only be obtained by passing the proper examination of the General Nursing Council and no other, an strongly urge, therefore, all nurses in institutions for mental defectives w 10 can become qualified before 1925 to make their application and get on the regis: er “while there is yet time. Whatever may be the future course of tiaining an *e kind of examination set up for admission to the register they at any late wi e entitled to all the privileges and status of a registered nurse.
The Council has now issued the syllabus of training for those nursing mental c efeetives and it will be necessary for all those not qualified and on t ic retois er . y Jnly, 1925, to carry out the prescribed training and pass the necessary examinations before they can gain admission to the register in the future. ie ram lng must include (1) Ward Instruction by sister or nurse in charge. (2) Demonstration and class instruction by Matron, Sister-Tutor, or other qualified Officer. (3) Three separate and distinct courses of lectures by Medical Officers, experience nurses, or other experts on the special subjects. (4) Periodical class examina tions conducted by the Institution Authorities in order to test progress A Schedule of practical instruction and a table of ward experience has to be filled m and signed by the proper officers of the Institution where the nurse is being trained ln order to provide a record of her training and experience.
It is especially laid down that mental nurses and nurses for mental defectives must produce evidence that they have been engaged in bedside nursing for at least six months. There are two examinations. The preliminary examination is the same for all nurses whether engaged in ordinary sick nursing or mental nursing, and consists of elementary anatomy and physiology, hygiene, and the first part of the theory and practice of nursing. The final examination covers the general duties of a nurse in a mental hospital, first aid, the second part of the theory and practice of nursing, bodily diseases, elementary anatomy and physiology of the nervous system, tfhe mind in health, mental nursing in institutions and private houses, and last of all a section on mental deficiency only four paragraphs out of sixteen of which are devoted to training. The Council states that the syllabus for the examinations has been adopted almost entirely from the revised syllabus for the Medico-Psychological Certificate with the exception of the Schedule of practical instruction which is a new departure.
It will be noted that nurses training mental defectives are expected to pass and presumably reach the same standard in the preliminary examination as those nurses doing ordinary sick work. It is also to be noted that the schedule of practical instruction consists almost entirely of the knowledge required in treating sickness of the body. It is drawn up from this point of view and bears little relation to the ordinary work of a nurse in a mental deficiency Institution. It requires the nurse, as I have already pointed out, to have had instruction in many things she will never need to know. But apart from a few items like First Aid it does not require her to have had instruction in most of the things which will have been her daily work during training. At least half the syllabus should consist of things relating to training or occupations and more marks should be given for ability to bring forward a new idea in say oral manual training than for all the purely nursing knowledge in the whole examination. Will not the present syllabus stereotype that purely custodial treatment which has held us bound for years ? Not a single item in the practical instruction deals with the instruction of mental defectives, for instance the teaching them how to wash themselves. It is only fair to say that the Nursing Council most courteously invited the Superintendents of various institutions for Mental Defectives to a discussion on the syllabus and accepted several suggestions cutting out useless things, but I personally gained the impression that especially as regards the practical instruction in sick nursing there was not much hope of any change in our favour, that the register was intended primarily for nurses, i.e. those who nurse bodily ailments, that it was a necessity for the examination there be some knowledge of this kind of nursing and that the amount required in the schedule was a minimum. I also understood that the nurses on the general part of the register would be required to show a much greater knowledge of bodily ailments and their care than would be expected of the nurses on the special register for those who train mental defectives, and it is true the scope of an examination depends less on the actual wording of the syllabus than on the interpretation put on it by the examiners and the parts of the syllabus from which the questions are mostly drawn.
In spite of this I cannot help feeling that as regards nurses in mental deficiency institutions we are beginning at the wrong end. Criticism in this respect necessarily implies some criticism of the theoretical part of the syllabus of the Medico-Psychological examination as this has been adopted by the General Nursing Council. I write with diffidence and partly for the purpose of provoking discussion, but I feel the time has come when the status and training of the staff in institutions for mental defectives should be considered and some action be taken. The name of Nurse is rightly honoured, the high sense of duty and selfsacrifice, of putting the human and personal need of the individual patient before everything has become so attached to the name that no-one could wish to give it up. It is, I am sure, the aim of the staffs in the mental deficiency institutions to treasure this name and to be no whit behind the nurse in a general hospital in their devotion to their patients, and I have been glad to know many who have never considered themselves but always first their patients. The fact remains, however, that there is a definite cleavage of the ways between the knowedge required by the majority of the staff in a mental deficiency institution and hat of the nurse in a general hospital or private practice. I will briefly take the syllabus of training and examination section by section and indicate what in my opinion is not required. This may provoke detailed criticism, make for thought, and I hope bring forth more valuable suggestions:?
Section I. General Duties of Nurses in a Mental Hospital. Much of this is yaluable but more stress should be laid on the correction of faulty habits and the instruction of patients in doing things for themselves, and such items as restraint, seclusion, and drugs might well be cut out.
Section II. Elementary Anatomy and Physiology. Section III. First id. Section IV. Hygiene. Section VII. Elementary Anatomy and Physi? ?gy of the Nervous system. A certain amount of elementary anatomy, physi?Sy> and hygiene, and especially first aid is desirable, and these sections do not go further than is perhaps necessary provided the word elementary is remembered oy the examiners.
Section V. Theory and Practice of Nursing. Much of the theory and praclce of nursing, though interesting enough and splendid training, is not required y the majority of the staff in institutions for mental defectives. For instance anket baths, water beds, care of the dead, splints, management of the sick room, Preparation for accidents and operations, rectal and hypodermic injections, urine estmg, blisters, douching, sponging, wet pack, cradles, sickroom cookery, etc. Section VI. Bodily diseases and their nursing requirements. Some simple nowledge is desirable in order that the staff may detect illness as early as possible and may know what to look for, but is anything more required ? Sections VIII & XII. The mind in health and mental nursing in institutions are both desirable.
Section XIII. This is the only section dealing directly with mental deficiency and it is followed by the schedule of practical instructions which is pracically all general nursing.
^ It will be seen that the outlook is almost entirely that of training a nurse to be k n^s ^or ^er patients, whereas the outlook in our institutions should surely e the teaching of nurses the best methods of training a defective to do things for niself and other people. We are schools rather than hospitals, schools with Pa lents of all ages it is true, from two or three years old to seventy or eighty, none the less places of training for the people we look after. We are not concerned much so far as present knowledge goes with drugs or medicines but with naergarten and oral-manual methods of instruction, with every kind of manual cupation and every kind of trade, so that in one way or other occupations and usefulness may be found for the great majority of all our patients. Our aim is not even so much the finding of occupations and employment for the higher grade patients; that almost solves itself. They become the skilled tradesmen of our colonies. Even the medium grade patients who can never hope to rise above the stitching of linings, or the heeling of a boot, are not such a hard problem, but the most difficult thing of all is the finding of useful and sufficient occupation for the lower grade patients, those who can never be more than, many not as much as, the general labourers of our kingdom. To all it is necessary to bring self-respect.
Even the high grade need this. Any number of these higher grade girls have been in one situation after another in the outside world, never keeping any one more than a few weeks, badgered and bullied ever since they can remember anything. They have lost all hope of making good and drift often to the streets. In the same way and for the same reason there are the boys drifting to petty crime because there is nothing else, to rough and violent habits because there is no outlet for their physical energy. The regaining of self-respect is one of the first needs for everyone of these, but the medium and lower grade need this same tonic. All their lives they have lived with the sense of inferiority, never able to do the same things as their brothers and sisters, often the butt of all who knew them, good tempered in intention though much of it may have been. It is the primary duty of our staff to give them this self respect and one of their most important duties to find the job this or that boy or girl can do. It may need a good deal of patience, and several trials, but there is nothing like the happiness of the defective who is beginning to feel that he is as good a man as his neighbour, that he has a job to do and that the Institution will not go on if he does not do it properly, and probably none of us quite appreciate the joy of a low or medium grade defective who has his wages raised to a penny a week, a joy that lasts till he begins to think that he is worth twopence.
Our aim and our ideals are high. They are most certainly not the mere custody of a given number of patients and seeing that they are properly cared for and treated; neither are they the same as that of the nurse dealing with bodily ailments. We do not want our staffs to be an inferior type of half-trained sick nurse for the body. We aim at their becoming teachers in the broadest sense of the word. Ours is to make a man or a woman just to the uttermost limit of possibility of every one of our patients, to see that they get their job in life and that they feel that most satisfying of all feelings, the importance of their job. I venture to suggest, therefore, that the type of training and examination suitable for the hospital nurse is not quite what is wanted for the staff in an institution for mental defectives. It does not emphasise sufficiently the training of the patients in habits and occupations, it emphasises too much the duties of a sick nurse. The trend of the mental deficiency institution of late years has been all towards treatment through occupation and training, all against being satisfied with custodial nursing.
The syllabus for many examinations nowadays is divided into two parts. One part comprises all those subjects which are compulsory for everyone entering for the examination. The other part comprises a number of subjects from which the candidate has to make a choice of one or two on which he or she will be examined. Would not this type of examination be more practical for the staffs of mental deficiency institutions than the one suggested? The compulsory subjects which everyone must take might consist of things like First Aid, Elementary Anatomy, and Physiology, Hygiene, The Mind in Health, etc., and most important of all Mental Deficiency. The subjects from which the candidate would have to select one or more in which she had specialised would include all those varied activities in training and occupations to be found in the ordinary institution for defectives such as special school teaching, oral-manual training, general handwork, needlework, all the special trades, physical training and exercises, housewifery, gardening, even farming, and of course one of these subjects in which a candidate could specialise might well be general nursing.
I know little of Mental Hospitals, but I gather from general reading that the trend in the mental hospital is in this same direction towards occupational training. If this is so, that is if occupations for the patients and re-education are tending to become a more important feature in the curative treatment given in mental hospitals, this fact will bring the work and the training of their staffs much more into line with the training of the staffs in institutions for the mentally defective than with that of the ordinary hospital nurse. In future, too, most institutions for defectives will be founded and maintained by the local authoiity for the county, that is by practically the same authority which already runs the mental hospital for the district. There will then be a greater impetus towards nurses moving from one of the county council institutions to the other, i. e. from the mental hospital to the mentally defective institution and vice versa. If this forecast is correct it does seem important now, when the syllabus of training and the examinations are being arranged, that these should be so drawn up as to make this movement of the staff from one institution to the other possible without a sacrifice of training or the necessity for an entirely different examination. It would seem easy to so arrange the suggested examinations that no loss of standing would act as an obstacle to prevent this movement. The examination I have suggested could for instance be made suitable for both types of institutions by allowing the nurse to take either mental deficiency or insanity as one of her compulsory subjects. A nurse having had her training and passed her examination in ?ne type of institution and transferring to the other type would then need, aftei a suitable interval, to pass an examination only in mental deficiency or insanity (i-e. whichever subject she had not previously taken) to be fully qualified for wor’ as a trained certificated and registered nurse in either of the two types of institutions.
May not our future, therefore, and that of the mental hospital nurse be fai ttiore in the direction of a register of nurses entered through a course of training and an examination such as that suggested which shall lay all or neaily all t e stress on training the patient as distinct from sick nursing him. Because sick nurses have obtained a very fine recognition we should not be content to hang on behind and trust to them to pull us up with them, we should climb y our own efforts though the direction may be slightly different and whether finally we reach success through the General Nursing Council or the Medicosychological Association.
(Correspondence on the subject of Dr Turner’s article is invited. Ed.)
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