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use in the hospitals in New York City. This, I believe, is the first more or less successful attempt made to analyze the "supply curve" of hospital facilities.

The figures as given in the table below are only approximately correct and refer to the year 1920. They are reproduced here as of possible interest to other communities as well as to the city of New York.

Distribution of Bed Capacity According to Service and Use in 182 Hospitals of

Greater New York

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Proprietary Beds Percent

203

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Total Percent 3,319 10.6

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♦Of these 273 beds are for children. ••Children's beds.

An examination of the table leads one to ask whether the provisions for certain types of conditions are adequate for the needs of the community. This would particularly apply to such conditions as those associated with the eye, ear, nose and throat, gynecology, urology, syphilis, neurology, industrial reconstruction and the care of the chronics.

The "supply curve" has no significance unless compared with the "demand curve." Unfortunately the actual or potential demands for hospital accommodations can not be determined very accurately because of the lack of morbidity statistics. With the exception of the prevalence of certain reportable diseases, we have no yardstick to gauge the problem of illness in its constituent elements. The various surveys and studies have given us a general idea as to the total amount of illness in a community but have done little more than this. With certain exceptions, such as in cases of contagious diseases, tuberculosis, and obstetrical conditions, we have not sufficient data at our disposal as yet to say accurately how many hospital beds of a certain kind a given community needs. The personal experiences of physicians and social workers in obtaining hospitalization for certain types of cases furnish some clue to the situation.

Middle Classes Need Facilities

In the light of the information which could be obtained as to this phase of the hospital situation, it would seem that the most pressing immediate need for extension of the hospital field in New York City lies in the direction of larger facilities for patients of the middle classes.

The general needs of the city as far as its own population is concerned seem to be fairly well met. New York, however, because of its medical renown, attracts a con

and, therefore, the sufficiency or insufficiency of hospital beds has to be gauged with that fact in mind.

The survey likewise brought out the need of additional convalescent facilities and a better correlation of the available accommodations in this realm. Certain types of conditions are well provided for while other types, such as nervous and borderline mental cases, are not adequately

considered. A study of 3,236 case records selected at random from the files of the social service departments of a group of hospitals showed that in 908 or 30 per cent of the cases there is a convalescent need. Of the 908 cases needing convalescent facilities, 23 per cent were adult males, 22 per cent adult females and 35 per cent were children under fourteen years of age. The existing ratio of accommodations between men and women does not correspond to the need as ascertained from the above analysis of records. There are inadequate facilities for men and adolescent boys as compared with women.

As has been stated above the provisions for chronic disease cases are not adequate, and with a few notable exceptions, the equipment of these institutions is meager and the amount of medical attention provided is insufficient for the need.

Very few of the general hospitals and not all of the institutions for chronic cases have utilized the opportunities offered by physio-therapy and occupational therapy.

The survey has further shown the need of larger nursing staffs in almost all of the hospitals, of more ample laboratory and x-ray facilities with adequate personnel, of the extension of the follow-up service, and a more careful and scientific supervision of the work of interns, nurses, dietitians and other professional agents of the hospital, of a greater utilization of hospital facilities for clinical research and teaching, and of more uniformity in the statistical, financial and efficiency accounting of the hospitals.

What was particularly striking as an immediate need was an agency in the city which would assemble facts concerning the work of the hospitals from year to year and which would be at all times in a position to inform the hospitals and the public as to existing conditions, immediate and future needs, and the prevailing practices and procedures. The public health committee of the New York Academy of Medicine accordingly recommended that such an agency be organized in the city. Recognizing this need the United Hospital Fund of New York established a bureau known as the Hospital Information Bureau whose purpose is to meet the need revealed by the survey.

'Ere long New York City will become one of the great medical centers of the world. It has all the elements necessary for this high destiny: vast clinical and research facilities, an abundance of medical talent and surgical skill, huge economic resources and a gradually developing spirit of community responsibility and cooperative helpTHE practice of reading aloud may, I suppose, be designated as an old-fashioned one since it appears to be done less and less often. People are not at home nearly so much these days as they were in times gone by and now there are many diversions that lead them from their library tables and their books. Yet the practice of reading aloud has not wholly disappeared; and it would be well indeed if in the future we would see a regTowth of it.

THE PRACTICE OF READING ALOUD TO INVALIDS

By THEODORE DILLER, M.D., Pittsburgh. Pa.

One can read a book alone to be sure. One can travel alone. One can view nature or paintings or churches alone; but every wholesome-minded person would sometimes prefer a companion so that he may pour out his own comments upon a sympathetic ear and receive in return those of his companion.

Who has not felt in reading a book that he would like to stop and comment upon this and that statement or description or criticism of the author! So it would seem to me there is the same reason for reading aloud that there is for a companion in enjoying scenery or works of art.

For men, women or children convalescing from an a 11— ress reading aloud ought to be particularly acceptable inasmuch as it is often fatiguing for the convalescent to read himself. Moreover, a book read aloud gives the convalescent the opportunity to comment and to enjoy the book sympathetically with the reader.

The Voice of the Reader

In these days of speech making we hear many voices: in church, on the platform and in the theater besides in ordinary conversation. There are all sorts of faults to be found with voices. Some are too loud and others too low. Some are sharp or nasal; one may speak too rapidly or too slowly or mumble. I have noted a curious thing, that sometimes a great singer does not possess a pleasing conversational voice. The most beautiful voice I have ever heard came from a woman who was nearly tone deaf and unable to carry on an ordinary tune. I know some voices that are pleasing to me apart from anything they have to say, and some that are habitually displeasing1. I have often heard a certain great scholar make addresses and after dinner speeches. His voice is very flat and grating to me, and yet this is a good man; he is very good man; he is very learned and talks sense.

One who reads aloud should raise his voice just high enough to be heard easily. He should read with some but not exaggerated expression, being careful to put in proper stops. Some persons can read rapidly and yet read well. The rapidity with which one reads should be gauged by his own powers of reading and the receptivity of the listener The reader should above all aim to read with simplicity.

Some people like books, some like them very much and some care for them hardly at all. And so, in reading aloud one should consider what to read. It is at once obvious this most depend largely upon the person read to. No very definite directions can be given. There is no particular class of literature suitable for the sick; but in a general way I fee' that newspapers should not be read to invalids It is better if even magazines are not read, but rather solid books, books of real worth. I see hardly any limit in the choice of books except the mental capacity of the hearer, a thing to which the reader should pay

most careful attention. This statement ought to be somewhat qualified. It is better generally to avoid books in which the imagination is greatly displayed, as in Victor Hugo or Poe. Humorous books are often very suitable but not always. It is a mistake to make too much of a studied effort to "cheer up" the invalid. Among suitable books I name Oliver Wendell Holmes, Washington Irving, Mark Twain; and I have often recommended Jane Austen and the old standard writers—Scott, Thackeray and George Eliot. It often happens that short stories are more suitable than long ones, and these we have in abundance. Nothing is better than those of O. Henry. Myra Kelly writes amusing stories about children. The reader must not weary the convalescent and he ought to be careful to watch for this.

Favors a Society for Reading Aloud

If reading is done in the right sort of way at the right time and not too long, I think it often happens that persons who have not cared for reading before come to like it. Personally I feel the habit ought to be cultivated both by well persons and invalids. In the hospital if the patient has a trained nurse in charge she will And ample time to read to him, but without special nurse he can hardly expect the nurses to take time to read to him. Here it seems to me is a great field for useful work for women of leisure—to visit hospitals and homes regularly for the purpose of reading aloud to those who enjoy it and who would profit by it If a sufficient number of women were banded together for this work of reading aloud all the reading that could be absorbed by invalids could be given without undue burden to any individual reader. If there were an organization in one of our large cities for reading aloud, it might be that such readers could receive instruction in the use of the voice and some hints of books to be read. I am sure that our public libraries would be ready to cooperate in this matter. It may be there is such a society in existence, if so I should like to hear something of it. It goes without saying that reading aloud should be done only with the approval of the physician in attendance.

The United States Government is conducting the largest trade and industrial school in the world. It has more than 130,738 students enrolled. This "school" is the rehabilitation division of the United States Veterans' Bureau through which the government is training these 130,738 veterans in a trade, industry, profession, business or in agriculture.

The instruction in these vocations is furnished in leading colleges, technical schools, commercial schools as well as in business establishments, shops and on farms. These men are in training in every state in the union and in every large city in the country. In all the large industrial centers these men who have received this intensive training from the government are available for positions. Every vocation is represented and any employer who needs additional personnel will be furnished such personnel from this vicinity in short time by notifying the Veterans' Bureau. Not only is this personnel trained in the best schools available but they have also received practical instruction on the job in industrial establishments and in shops.

Nursing And The Hospital

Conducted by CAROLYN E. GRAY. R.N.,
Department of Nursing Education, College for Women,
Western Reserve University, Cleveland, Ohio

NURSING EDUCATION AND THE AMERICAN

HOSPITAL*

By RICHARD OLDING BEARD, M.D., University Of Minnesota, Minneapolis

TO THE evolutionist who believes in an ever-evolving process, history has its chief interest in the afterglow it casts upon the present and the guidance it gives to the onward movement of tomorrow.

The history of nursing education is not coincident with the history of nursing. The latter may be roughly traced through four phases of social experience and while in the first two of these phases no formal attempt at education appears, they had, and perhaps continue to have, their influence upon the medical and popular view of nursing education. The first period is that of home nursing. It consisted merely in the exercise of the natural function of womanhood, and especially of the wife and mother, in the domestic care of the sick. In its exercise there was everything of tenderness and devotion, enlightened by the occasional, desultory instruction of the physician, who assumed to know more and usually knew less of nursing than the household nurse herself. Home nursing was the expression of the intuitive desire of woman to heal the sick, to bind up the broken of body or of spirit, to comfort those who suffer.

The home nursing period has never really ended. It not only overlaps the succeeding phases of history, but it persists through them all and perhaps it always will persist. The home nurse, frequently superseded, of her own volition, by the professional nurse yields her place, as the part of good intelligence dictates, to a more competent helper; but her potentiality of service remains, an inherent right backed by an inherent capacity.

Entrance of the Practical Nurse

Through all recorded time she usually played the part of a good neighbor and whenever she showed particular aptitude for nursing she stood on call in the community. She became, in a word, the parent of that unique composite figure who occupies the center of the second stage of nursing history—the experienced or practical nurse. In the course of time, with the growing complexity of society, an increasing number of women made a business of community nursing. Many of us can think back to the days when no other kind of a nurse was to be had for hire. Sometimes she was efficient and funded to very good results the experience of her passing years. Sometimes her capacity was in inverse ratio to the social need of

•An address delivered before the third annual convention of the Wisconsin Hospital Association at La Crosse. Wis., May 81.

her services and if her untutored mind happened to run in a narrow mold her society was more of a bane than a pleasure and her nursing was often worse than none. In her group, however, we recall women who were deserving of honor and of more substantial reward than they received. Occasionally, we employed one who proved superior to the early specimens of her presumptively trained successors.

For the third phase in the history of nursing visualizes for us the trained nurse. Florence Nightingale of blessed memory, systematically if chiefly self-trained, has always been regarded as the prototype of this group and that carries its evolution back to 1854. She was certainly the first to apply the science of her day to practical nursing and in doing this she undoubtedly established a new type. She became the administrator and the teacher of almost the first training school for nurses; but the attempt languished and it was reserved for America, almost a generation later, to set the type of school, if not the type of nurse, in this third period. It is a significant fact that the period of the trained nurse is coincident with the rise and development of the modern hospital.

In fact the hospital was the reason of being for the training school. Its economic survival was conditioned upon the pupil nurse. Like the early output of the trade school, she was simply apprenticed to the job, and while the period of her training was called a curriculum, it was nevertheless a period of service and often of very menial service at that. We may readily recall, in our western cities, the essentially domestic quality of the early graduates of the training schools. With all honor to their ambition for personal betterment, crudity was nevertheless their outstanding feature. I remember well my astonishment on my first visit to eastern schools of nursing to note the culture, the education, the refinement, as well as the economic independence of many of their pupilnurses.

Through forty years of the later development of the training schools I have watched with pleasure the progressive improvement in the quality of their registration; but I have wondered sometimes whether the indifferent attitude of some professional men toward nurses is not a relic of the earlier sense of their inferiority; whether it has not served, in part, to shut the eyes of the physician to the wonderful work of the generally wonderful body of women who make up the nursing profession of today. Nurse Reacts Against Repression

I know there are those who even refuse to accord to the calling of a nurse the dignity of a profession. They are simply living in a past when nursing was accounted the function of the domestic. As hospital administrators, these men—for I am sorry to say that they who take this attitude are men—have succeeded sometimes in determining the non-professional status of their pupil nurses, so long as they remained in the hospital school; but a harvest of resentment follows that sort of sowing in the minds of students. The reaction of the repressed woman is toward a professionalism all the more keen and, too often, self-assertive.

For nearly fifty years the institutional or hospital school was the only opportunity of training open to the nurse, the only source of supply of the graduate nurse for private duty or hospital special service. The country is, in fact, deeply indebted to the hospitals for the institution of private nursing in America. The nurse of those early days did not care very much about training. She was content with the school of experience and hard knocks although it was commonly: the patient who had to take the punishment. The public had never known anything better than the practical nurse and did not demand that she be trained. But the hospital needed the efficient nurse. It could only get her by training her and rather eagerly and miscellaneously it undertook the task. The training schools multiplied. The organization of a new hospital, whether good, bad or indifferent, carried with it, as a matter of course, a new training school. Too often the nurses' training has been a mere matter of technique. Too often automata in nursing have been turned out. who caught nothing of the inspiration of a profession and were innocent of the spirit of social service. They were deserving rather of commiseration than of blame, for they were the output of a too rigid hospital system and they were too frequently exploited for the benefit of the hospital they served. They might be expected to take their toll of the public since the hospital had taken rather ruthlessly its toll of them.

Nurses Became Dissatisfied

For a dozen years before the War, the symptoms of dissatisfaction with the prevailing system were not wanting among nurses. It was not infrequently said that the extension from a two to a three year training course was in the interest of the hospital service rather than in the interest of the nurse in training. Undoubtedly the lengthening of the course, whether justified or not, was sometimes adopted as a means of slowing up the output of nurses, because with the multiplication of hospital training schools a curious thing had happened. More nurses had come to be needed as undergraduates in hospital service than society

needed as graduates on private duty. I made a rather widely extended survey of private nursing in 1908, with the discovery that at that time the nurse in practice was employed on an average of seventy i>er cent of her time; and by that period society had pretty well developed the expectation in sickness of the services of the trained nurse. And in that day the fee for private nursing was only $15 to $20 a week. There was definitely no shortage of nurses in private practice, and the employment of nurses in public health service was at that time limited to only a very negligible number.

The deficiency of nurse> in the hospitals finally became sufficiently marked to lead to the practice of employing graduate nurses in special hospital service, a practice which has grown in the past twenty years. Very naturally the hospitals found the shrinkage of registration an occasion for concern and discussion of the policies of nursing education developed in hospital and medical associations alike. Curiously enough, it hardly seemed necessary to consult the nurses themselves and this lack of cooperation and counsel still measurably continues. In the first instance, their isolation might be traced to a lack of organization.

The profession of nursing, under the leadership of Isabel Hampden Robb, had only begun to organize in the later years of the last century, but it had attained no direct initiative, no solidarity of influence. It was still under the sway of hospital administration. It had hardly begun to act or even to think for itself. It had not acquired a semblance of the strong professional spirit which actuates it today.

Nevertheless, the time was ripe for change in the nursing world. I do not know whether the incidence of events is unconsciously governed by the tides of human thought, but I remember well an experience in June, 1910, which announced not only that a new phase in the history of nursing had been initiated, but that the day of the educated nurse, as opposed relatively speaking to the trained nurse, had come and come to stay. There are those of us hold still to the faith that "What is good—as God lives —is permanent."

In that year, a fortunate bequest had given to the University of Minnesota a teaching hospital and some of us sensed the opportunity to propose the creation of a university school of nursing. We drafted a plan of organization which was adopted by the board of regents. Hardly had this been done when the national organizations of nursing met in Minneapolis. At a joint session, gathering, perhaps, the largest number of nurses ever assembled up to that time, an address was given upon "The University Education of the Nurse" and, without any previous knowledge upon the part of the audience, the action of Ihe University of Minnesota was announced. Instantly, with an electric wave of enthusiasm, that great congregation of women was on its feet in spontaneous appreciation of a new destiny. The movement has wonderfully developed. In twelve years ten university schools of nursing have been established, while several affiliations with teaching institutions of varying intimacy and more or less doubtful value have been formed.

■BARGAIN" OR FIVE-YEAR COURSES

"Short courses for nurses have had the history of a bargain tale. Then draw cheap bunerg out after cheap goods, and the supply of either soon exhausts itself. The output of these schools belongs to the social order of the ephemera. They are 'little creatures' who have their dan and cease to be.

"Thai high standurds of nursing education invite rather than repel students is shown by the fact that the five-year combined courses in arts and nursing offered by fifteen of our major universities in the past year or two are already finding ready takers.

"I believe we are very close to the parting of trays in nursing education. J have no fear that we shall go backward. The tide may temporarily recede, but ebb is always followed by flow. Cheap expedients for increasing nursing registration will not succeed. Students will not accept what they do not want. The problem is one of adjustment. It is a question soon to be met between institutional and university methods of education."Dr. Beard.

The First University Training School

The pioneer school at Minnesota, to which the early critics allotted an early death, has maintained the standards with which it started. It is a collegiate school. It enters high school graduates. It gives a preliminary course of scientific instruction. Its growth has been limited by the capacity of its teaching hospital and of the reaction which the limitation has created I shall later have something to say.

Since the year 1910 "much water has passed under the bridge" and many new occasions have taught new duties in nursing education. The great war has been, and the profession of nursing, with everything else in human society, has been disorganized. The response of American nurses to the call of the country in the military and naval services gave witness to the quality of their national devotion, to their capacity for sacrifice, to their sense of professional honor. The draft upon the nursing profession, if temporary, was severe. Some of them did not come back, and those who did came back to find that their own widened sense of opportunity, of a higher destiny in nursing, had been met by the sharply awakened consciousness of the people to the already serious deterioration of the public health, discovered by the statistics of the war. The reaction of the people has been and remains keen. An impetus, never experienced before, has been given to every form of public health activity. The American Red Cross and the National Organization of Public Health Nursing found themselves in the grip of a great emergency and they met the call for competent nurses and for higher education to make them competent, very nobly. The Red Cross peace program pivoted upon the public health and if it be true, as the newspapers report, that the House of Delegates of the American Medical Association has called for a cessation of Red Cross activities in this field, it is greatly to the discredit of the medical profession. It is a matter for regret to many of us who belong to that profession that it has taken so slight an interest, so small a part, in preventive medicine. The claim that politics enters into public health work is a trivial one. It enters into medical organizations as well, and it is only a question of keeping the politics clean. The American Red Cross has not paralyzed; it has been a tremendous stimulus to community interest and responsibility.

Of one thing we may rest definitely sure. The public health program of the people of America is not going to be stopped. The demand for adequately educated nurses in the widening fields of public health activity is going to continue. Women, as nurses, provided they are fitly educated, are the best promoters of public health interests to be found. They find school and home and public forum open to them and already they have given, in visiting nursing, in infant and child welfare work, in public school nursing, in rural community nursing, in industrial nursing, in medical social service, abundant proof of their capacity to serve.

To the superficial observer, not well informed of existing conditions, the temptation comes to let down the educational bars, to propose short courses, to offer a premium to pupils as though they were fish to be caught by bait.

One year, two years, we are told are sufficient to give nurses adequate training. It is fondly hoped that if their education is foreshortened they will work for lesser wages, while all experience has proved that the graduate of the two-year school will ask as much for her services as the three-year graduate. It would not take long for the oneyear trained nurse to think herself as good as her better trained competitors and to adopt the same wage scale. Professional ethics and individual conscience are matters of education and the less educated the nurse the less likelihood is there of development in her of the spirit of social service. Moreover, we may as well say frankly that the only argument for the rapidly educated nurse is the hospital need and that is not enough to justify a cheapening of nursing education.

Let us take a little account of the facts: Admitted that registration of pupil nurses is lessened, where is the deficiency the more and where is it the less critically felt? It is the small, the inferior, and frequently the short course schools that are the keenest sufferers. The superior group of hospital schools and the schools under university ownership and control are entering increasing and often adequate numbers. The conclusion is very clearly drawn. Women who are seeking a vocation today and particularly women who are entering the profession of nursing are seeking the best education they can get. They are looking not only to private and hospital practice. They expect ultimately to reach out into the higher opportunities of public service. They do not want to be "sub-nurses."

"Bargain Sale" Courses for Nurses

The six weeks' course for nurses of Dr. John Dill Robertson of Chicago has had the history of a bargain sale. It draws cheap buyers out after cheap goods, and the supply of either soon exhausts itself. The output of these schools belongs to the social order of the ephemera. They are "little creatures" who "have their day and cease to be."

That high standards of nursing education invite rather than repel students is shown by the fact that the fiveyear combined courses in arts and nursing offered by fifteen of our major universities in the past year or two are already finding ready takers. The two years of academic work, the two years in the school of nursing, and the fifth year in advanced study in specialized nursing, public health service, or nursing education are proving attractive. I look to see these five-year courses become the great feeders of the university schools. They lead to the double degrees of Bachelor of Science and Graduate in Nursing.

I believe we are very close to a parting of the ways in nursing education. I have no fear that we shall go backward. The tide may temporarily recede, but ebb is always followed by flow. Cheap expedients for increasing nursing registration will not succeed. Students will not accept what they do not want. The problem is one of adjustment. It is a question soon to be met between institutional and university methods of education.

Two or three things stand out clearly to be reckoned with: The economic need of the hospitals for nursing service must not only be considered, but it must be met. While the hospital is not naturally an institution of learning, it is an instrument of education. It must remain the laboratory in which the nurse receives her practical training. It should confine itself to that function under the standardizing direction and the educational control of the university school.

By association with the university school, as its clinical laboratory, the hospital exercises in behalf of the nurse, precisely as it does in behalf of the medical student, a

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