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SPECIAL ARTICLES

THE SHORTAGE OF NURSES

NEW PROPOSALS

THE Inter-departmental Committee on NursingServices, appointed in November, 1937, by theMinister of Health and the President of the Board ofEducation, has not waited until it can present acomplete report on its very wide terms of reference.The statistical material on which it proposed tobase its final conclusions cannot yet be summarised,but the public anxiety about the maintenance ofan adequate institutional nursing service has led itto make an interim report 1 on the most urgent ofthe problems presented to it. The introductory noteacknowledges the help given to its considerationof nursing problems by the report (1932) of THELANCET Commission on Nursing and adds : "...we think that many of the improvements whichhave been made in hospital conditions in recent yearsare directly attributable to the recommendationscontained in that Report." It is common knowledgehowever that the shortage both of probationers andof trained nurses applying for work in hospitals hasbecome more acute, relatively to the need, duringthe last six years. Besides endorsing most of therecommendations made in 1932 the committee has

brought forward constructive new proposals and itis these that we propose to outline.

SALARIES AND PENSIONS

The committee is agreed that having regard totheir great responsibilities nurses are badly underpaid,especially in the higher posts, even when theiremoluments are taken into account. It deplores thecompetition between employing bodies for the availablepersonnel as a method of raising salaries and suggeststhat pay and pensions should be treated on a nationalbasis by the establishment, on the initiative of theMinistry of Health, of one or more committees similarto the Burnham committees, composed of repre-sentatives of employers and employees, which evolvednational scales of salaries with regional applicationfor the teaching profession. It is proposed that thecost of a general improvement in salaries (whichcost will be increased by that of the employment ofadditional staff needed to carry out what is regarded as" another essential reform "-namely, the reductionof hours of duty to 96 per fortnight) should be metby two types of grant : (1) payable in respect of workdone in training nurses and (2) payable in respectof increased expenditure incurred on nursing services.The first type of grant would be derived from nationalfunds, available to voluntary and municipal hospitalsalike, and administered centrally by the Ministry ofHealth ; the second would be given only to voluntaryhospitals and administered through the local authority.These suggestions are subject to reservations signed

by eight members of the committee. Three are

unable to support grants specifically in respect of thetraining of nurses when the training-school is savingthe hospital money by employing probationers tosupplement the work of trained nurses. Threemembers are joined by another in a refusal to expressany opinion as to the source from which grants shouldbe provided to voluntary hospitals which are unableto carry out the recommendations of the report onsalaries and hours of work ; and four other members,

1. H.M. Stationery Office. Pp. 93. 1s. 6d.

though in full agreement about the need for improvingsalaries and conditions of service, do not regard thefinancial basis of the proposals as equitable in so faras large expenditure would be incurred by localauthorities on what is regarded as a national problem.These reservations are conspicuous because amongthe many controversial questions considered a

remarkable degree of unanimity has been achieved ;only two other notes of reservation (to be mentionedpresently) are recorded.The committee is sure that pensions for nurses

should be universal and interchangeable, but thedifficulties of achieving this are clearly set out in amemorandum from the Government actuary in anappendix to the report. He suggests (and thecommittee concurs) that the most helpful line of

approach is by the method known as " cold storage "under which each separate period of service earnsa separate pension only when the employee ultimatelyretires.2 s The service counts for pension whetherit is with a voluntary hospital or other body whosestaff is affiliated to the federated superannuationscheme for nurses and hospital officers or under alocal authority.Though under this method the total superannuation

rights earned may be less than those of a continuousservice under one authority, the fact that a transferfrom one service to another usually implies promotionmay ultimately neutralise any loss. Attention isdrawn to the fact that as both in voluntary andmunicipal hospitals superannuation contributionsare paid on salary plus emoluments-i.e., estimatedcost of board and lodging-it is unfair for the emolu-ments of nurses who live in hospital to be reckonedless for superannuation purposes than the cashallowances given to those who live out. The latterare therefore favoured. In view of the small numberaffected it is surprising to learn that witnesses assuredthe committee that this is already " a cause of greatdissatisfaction in the profession " ; but we agreethat it might well become so if recommendations 22and 27-in favour of extending the system of living-out for the trained staff and of the practice of

employing married nurses-are adopted. Pendingthe establishment of salaries committees the anomalycould, it is suggested, be remedied by reckoningpart of the cash allowance granted to a nurse wholives out as a non-pensionable emolument, ratherthan by throwing an extra financial burden on thehospitals by scaling up the salaries of all nursesliving in.

HOURS OF WORK

The introduction of a 96-hour working fortnight,exclusive of time spent at meals, for all grades ofinstitutional nurses both on day and night duty isa unanimous recommendation. Witnesses beforethe committee were agreed that only if this figurewere reached could the nursing profession standcomparison with the hours worked in most of thealternative careers open to women. This viewrepresents a definite (and, we believe, satisfactory)change of attitude to the question of hours of work,for only six years ago responsible nursing organisa-tions in evidence to THE LANCET Commission regardeda 56-hour week spread over a fortnight-i.e., a 112-hourworking fortnight-as a satisfactory maximum.

2. This method was also recommended on the same advice bythe committee on nursing set up by the Secretary ofState for Scotland under the chairmanship of Lord Alness(see Lancet, 1938, 2, 1086).

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Then as now legislation to enforce a maximum wasnot generally favoured. The committee regardssuch legislation as both undesirable and unworkablein practice ; pressure could, it holds, be broughtto bear on any hospitals reluctant to introduce a96-hour working fortnight either through the nursingorganisations or, if necessary, through the recom-mended system of grants. Five members (in a noteof reservation) do not agree that " the professionitself is resolutely opposed to having its hours ofwork regulated by statute " and believe that onlyby legislation-which would have to settle an,-

appointed day " some years in advance-would itbe possible to ensure the institution of a 96-hour

working fortnight at a reasonably early date.The recommendation that extra work in an

emergency should be recognised by additional hoursoff duty, rather than by payment for overtime, isunanimous.

RECRUITMENT

The desirability of a central bureau to controlrecruitment is suggested. There is evidence, especiallyin London, that intending probationers may bediscouraged and lost to the profession because thehospital to which they first make application has novacancies. In some districts in the provinces a

central office of this kind would perform a usefulfunction both for voluntary and municipal hospitals.Such a bureau could establish effective contact betweenhospitals and education authorities and with girlsleaving school; the bureau could supply informationon qualifications required, on facilities offered and onprospects ; it could keep a register of trained nursesand advertise in the press. The committee holdshowever that any official publicity campaign for

nursing would be premature until the conditions ofemployment have been altered on the lines of itsrecommendations.On balance of evidence the age of 18 is recom-

mended as the minimum for entry to the wards ofa general hospital, although 19 would be desirable.In the future it is hoped that special hospitals willbe able to raise their age of admission to 18 ; inno case should any girl be allowed to start nursingduties under the age of 17, though younger ones maybe employed in other hospital departments.

It is impossible, in the committee’s view, to obtainenough probationers from girls educated at secondaryschools ; recruitment must be directed towards the

elementary schools as well. The chief inspectorof the Board of Education is quoted as authorityfor the belief that the best products of elementaryschools are capable of becoming good nurses and wouldfind little difficulty with the state examinations.The committee regards the resolution of the GeneralNursing Council to divide the preliminary stateexamination as the one step which can be of materialvalue in bridging the gap between school and hospital.The secondary-school girl should be able, after a

full course of one year’s duration, to take part 1of this examination (anatomy, physiology and

hygiene) ; the ex-elementary-school girl who is infull-time employment will be required to spread apart-time evening course over two years. If she isnot employed during the day she could fill in twoyears between 15 and 17 by study at a technicalinstitution.The committee does not favour special nursing

scholarships at secondary schools, holding that anyfinancial assistance to enable girls to continue theireducation beyond the age of 16 should be inde-

pendent of the profession to be chosen by the pupil.

Girls likely to be specially suitable for nursing mighthowever be granted assistance by local educationauthorities even if they had not obtained the schoolcertificate.

THE TEST EXAMINATION

The examination in English, general knowledge andarithmetic, recently instituted by the General NursingCouncil for girls who have not obtained the schoolcertificate, has in the committee’s view intensifiedthe difficulties of recruiting probationers. It hasdeterred some girls from considering a nursingcareer, and has increased the burden on sister-tutorsand on those probationers accepted at hospitals onthe condition laid down by the General NursingCouncil that they pass the examination within threemonths of entry. The sole function of such an

examination should be to exclude from the training-schools those who are unlikely to pass their profes.sional examination. The thesis that the test examina-tion should not be obligatory on those who havepassed the first part of the preliminary state examina.tion is supported by convincing argument. Thecommittee contemplates that the usual method ofentry to the profession should ultimately be by wayof a pre-nursing course in which general subjects,such as arithmetic, will be included. Meanwhileit is suggested that the age of admission to the testexamination should be reduced from 17 i to 17,that the system of prior acceptance of the candidateby a matron should be discarded and that the scopeof the examination should be made more suitablefor candidates from an elementary school.

WHITLEY COUNCILS

The recommendation that governing bodies of

hospitals who have not recently revised their rulesshould do so with the assistance of probationers aswell as of representatives of the nursing staff is a

good example of the general tenor of the report, inits implied criticism of the current militaristic attitudeto the trainee. This idea is developed into a suggestionthat not only a nurses’ representative council, withaccess to the matron, but one constituted on the linesof a Whitley council should be established in everyhospital. The " staff side " should include repre-sentatives of the probationers and should meetregularly ; a delegate from this side could settle byinformal discussion with a representative of the" official side "-e.g., the matron-many minor

questions which need never be brought up at formal(and infrequent) meetings of the full council. Theimportant aspect of this proposal seems to us thetacit recognition that the matron in whatevermaternal relation she desires to stand to her nursesis necessarily influenced by loyalty to their employers.Often hospitals undertake quite lightly responsi-bilities to patients which they cannot fairly fulfilwithout a much greater annual expenditure than wascontemplated and such enterprises may press hardlyon a depleted nursing staff. The dual r6le of thematron makes her position of divided loyalties a

particularly difficult one. Her authority would notsuffer and her position as go-between would be easedif the nurses’ representatives had direct access torepresentatives of the governing body of the hospitalat meetings where she would take her place on the" employer’s side " where she really belongs, howeverzealous her private efforts to secure better conditionsfor her staff.We agree with the committee that such a council

might not only remove causes of friction but wouldgive the nurses, including probationers, valuable

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experience of the problems of hospital administrationand enlarge their outlook. The committee envisages,in course of time, the development of a nationalcouncil charged with the consideration of conditionsof service in the broader aspects, but it holds thatthe first step to this end is the successful anduniversal adoption of local councils.

A SECOND GRADE OF NURSES

The frank admission in the report that, whateverthe improvement in recruiting, it will not be possiblefor some years (or perhaps ever) to carry on the

nursing services of the country without the aid of"assistant nurses" clears the ground. The oppo-sition in the profession to the official recognition of asecond grade of nurses has been founded as muchon the conviction that the basic training leading tostate-registration is the minimum that will protectthe public from the very real dangers of incom-petence in private nursing, as on a natural desire toprotect the status and economic position of registerednurses. But the fact that so many unregisteredwomen are working in institutions (sent as "tem-porary" " helpers from nursing cooperations), in

nursing-homes, and in private houses, without anyguarantee of the extent of their training, or of theircharacter, makes it essential on all grounds todifferentiate those capable of rendering useful servicefrom others who are unsuitable for such work.

It has often been assumed that it is only thechronic sick who could safely be entrusted to the careof a second grade of nurse. The committee does notstress this point, but would restrict their employmentin hospitals to work done under the supervision of atrained nurse. In domiciliary nursing the safeguardto the public would be licensing, registration andinspection by local authorities of all agencies andcooperations supplying private nurses. Such coöpera-tions would be forbidden to supply nurses not enteredon a state register or on the roll of

" assistant nurses,"and would be required to inform the patient whichtype of nurse was being sent out. The committee

expresses the opinion that no women except those onthe registers or the roll or those in training should" habitually and for gain " nurse the sick ; but itreserves for further consideration a suggestion thatlegislative measures should be taken to secure thisend. Existing " assistant nurses " should, they hold,be admitted to the roll, which should be placed underthe control of the General Nursing Council, on

evidence of competence, two years’ experience andgood character. In the future somewhat similarqualifications would be demanded of candidates overthe age of 21.No detailed consideration is given to a scheme of

training, but importance is attached to preliminaryapproval of training institutions which would notnormally but might in certain circumstances behospitals also recognised as training schools for state-registered nurses. An excellent suggestion is that thetest in practical nursing (there would be no writtenexamination) which would be a condition of admissionto the roll should take the form of an inspection byassessors of the candidate’s work in her normalenvironment at her hospital. The service would, it isbelieved, appeal to older women dissatisfied withtheir present occupation and would release manystate-registered nurses for more highly skilled work.

It is noteworthy that the recommendation for therecognition of a second grade of nurse, thoughendorsed in principle by all members, is subject to areservation on nomenclature signed by the nurses on

the committee. Thoy advocate as an official designa-tion that of "registered invalid attendants."

CONDITIONS OF SERVICE

The general conclusions so far reached agree sub-stantially with those formulated by TIlE LANCETCommission. They advocate reasonable notice oftimes ofE duty, preferably by means of the universaladoption of time-tables; the relief from hospitalduties of probationers about to sit for a stateexamination ; at least four weeks of annual leave, ofwhich two should be consecutive ; better accommoda-tion in a number of hospitals ; an extension of theliving-out system for trained staff ; the abolition ofunreasonable rules and restrictions, and a more

friendly atmosphere in hospital ; the conduct of thenurses’ home as a hostel; better facilities for recrea-tion and the pursuit of social life outside the hospital ;an improvement in catering, and the removal ofvexatious restrictions regarding attendance at meals ;the provision of domestic help for routine duties.It is recommended that a nurse confined to bed orabsent from duty for more than twenty-four hoursshould be examined by a medical officer. Routinemedical inspection of the nursing staff at intervals

during training is carried out in Germany and is

regarded by the committee as an admirable practicewhich might with advantage be adopted as a routinein British hospital practice.

HYDATIDIFORM MOLE

AND CHORIONEPITHELIOMA

MR. BREWS’S BLAIR-BELL LECTURE

AT the Royal College of Obstetricians and Gynfe-cologists on Jan. 27 Mr. ALAN BREWS delivered thesecond William Blair-Bell memorial lecture. It wasbased both upon his own experience and on an

analysis of case-records from the London Hospital,comprising 100 consecutive cases of hydatidiformmole treated during a period of thirty-three years,1905-37, and 26 consecutive cases of chorionepithe-lioma treated during a period of fifty-three years,1885-1937.

HYDATIDIFORAI MOLE

Lamotte, said Mr. Brews, may have been the first,in the 18th century, to associate the terms hydatidand mole, and the first recognition that the hydatids sare cystic dilatations of the chorionic villi was attri-buted to Velpeau and Madame Boivin (1827).Virchow (1853) still considered that the essentiallesion was a degeneration, affecting the stroma ofthe villi, and the modern conception of excessive

proliferation of syncytium and Langhans cells as

the primary morbid change originated with Marchand’smonograph (1895). That the term hydatidiform moleis not truly descriptive was evident from the factthat the foetus may survive and be born as a livinghealthy child.

Excess of gonadotrophic hormone in the urine ofpatients suffering with this disease was first demon-strated by Fels and Ehrhart in 1929. Recently,with the aid of the dissecting microscope, Meyer haddemonstrated chorionic vesiculation to a varyingextent in nearly a third of a large number of

spontaneous abortions examined.Eo!o</.&mdash;In the lecturer’s opinion the available

evidence points to the condition being a primarydisease of the ovum.