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Petty management.

All the results of good nursing, as detailed in these notes, may be spoiled or utterly negatived by one defect, viz.: in petty management, or, in other words, by not knowing how to manage that what you do when you are there, shall be done when you are not there. The most devoted friend or nurse cannot be always there. Nor is it desirable that she should. And she may give up her health, all her other duties, and yet, for want of a little management, be not one-half so efficient as another who is not one-half so devoted, but who has this art of multiplying herself—that is to say, the patient of the first will not really be so well cared for, as the patient of the second.

It is as impossible in a book to teach a person in charge of sick how to manage, as it is to teach her how to nurse. Circumstances must vary with each different case. But it is possible to press upon her to think for herself: Now what does happen during my absence? I am obliged to be away on Tuesday. But fresh air, or punctuality is not less important to my patient on Tuesday than it was on Monday. Or: At 10 p.m. I am never with my patient; but quiet is of no less consequence to him at 10 than it was at 5 minutes to 10.

Curious as it may seem, this very obvious consideration occurs comparatively to few, or, if it does occur, it is only to cause the devoted friend or nurse to be absent fewer hours or fewer minutes from her patient—not to arrange so as that no minute and no hour shall be for her patient without the essentials of her nursing.

Illustrations of the want of it.

A very few instances will be sufficient, not as precepts, but as illustrations.

Strangers coming into the sick room.

A strange washerwoman, coming late at night for the "things," will burst in by mistake to the patient's sick-room, after he has fallen into his first doze, giving him a shock, the effects of which are irremediable, though he himself laughs at the cause, and probably never even mentions it. The nurse who is, and is quite right to be, at her supper, has not provided that the washerwoman shall not lose her way and go into the wrong room.

Sick room airing the whole house.

The patient's room may always have the window open. But the passage outside the patient's room, though provided with several large windows, may never have one open. Because it is not understood that the charge of the sick-room extends to the charge of the passage. And thus, as often happens, the nurse makes it her business to turn the patient's room into a ventilating shaft for the foul air of the whole house.

Uninhabited room fouling the whole house.

An uninhabited room, a newly painted room,11 an uncleaned closet or cupboard, may often become a reservoir of foul air for the whole house, because the person in charge never thinks of arranging that these places shall be always aired, always cleaned; she merely opens the window herself "when she goes in."

Delivery and non-delivery of letters and messages.

An agitating letter or message may be delivered, or an important letter or message not delivered; a visitor whom it was of consequence to see, may be refused, or one whom it was of still more consequence not to see may be admitted—because the person in charge has never asked herself this question, What is done when I am not there?12

At all events, one may safely say, a nurse cannot be with the patient, open the door, eat her meals, take a message, all at one and the same time. Nevertheless the person in charge never seems to look the impossibility in the face.

Add to this that the attempting this impossibility does more to increase the poor Patient's hurry and nervousness than anything else.

Partial measures such as "being always in the way" yourself, increase instead of saving the patient's anxiety. Because they must be only partial.

It is never thought that the patient remembers these things if you do not. He has not only to think whether the visit or letter may arrive, but whether you will be in the way at the particular day and hour when it may arrive. So that your partial measures for "being in the way" yourself, only increase the necessity for his thought. Whereas, if you could but arrange that the thing should always be done whether you are there or not, he need never think at all about it.

For the above reasons, whatever a patient can do for himself, it is better, i.e. less anxiety, for him to do for himself, unless the person in charge has the spirit of management.

It is evidently much less exertion for a patient to answer a letter for himself by return of post, than to have four conversations, wait five days, have six anxieties before it is off his mind, before the person who is to answer it has done so.

Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion. Remember, he is face to face with his enemy all the time, internally wrestling with him, having long imaginary conversations with him. You are thinking of something else. "Rid him of his adversary quickly," is a first rule with the sick.13

For the same reasons, always tell a patient and tell him beforehand when you are going out and when you will be back, whether it is for a day, an hour, or ten minutes. You fancy perhaps that it is better for him if he does not find out your going at all, better for him if you do not make yourself "of too much importance" to him; or else you cannot bear to give him the pain or the anxiety of the temporary separation.

No such thing. You ought to go, we will suppose. Health or duty requires it. Then say so to the patient openly. If you go without his knowing it, and he finds it out, he never will feel secure again that the things which depend upon you will be done when you are away, and in nine cases out of ten he will be right. If you go out without telling him when you will be back, he can take no measures nor precautions as to the things which concern you both, or which you do for him.

What is the cause of half the accidents which happen?

If you look into the reports of trials or accidents, and especially of suicides, or into the medical history of fatal cases, it is almost incredible how often the whole thing turns upon something which has happened because "he," or still oftener "she," "was not there." But it is still more incredible how often, how almost always this is accepted as a sufficient reason, a justification; why, the very fact of the thing having happened is the proof of its not being a justification. The person in charge was quite right not to be "there", he was called away for quite sufficient reason, or he was away for a daily recurring and unavoidable cause: yet no provision was made to supply his absence. The fault was not in his "being away," but in there being no management to supplement his "being away." When the sun is under a total eclipse or during his nightly absence, we light candles. But it would seem as if it did not occur to us that we must also supplement the person in charge of sick or of children, whether under an occasional eclipse or during a regular absence.

In institutions where many lives would be lost and the effect of such want of management would be terrible and patent, there is less of it than in the private house.14

But in both, let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?

Then, when anything wrong has actually happened in consequence of her absence, which absence we will suppose to have been quite right, let her question still be (not, how can I provide against any more of such absences? which is neither possible nor desirable, but) how can I provide against any thing wrong arising out of my absence?

What it is to be "in charge."

How few men, or even women, understand, either in great or in little things, what it is the being "in charge"—I mean, know how to carry out a "charge." From the most colossal calamities, down to the most trifling accidents, results are often traced (or rather not traced) to such want of some one "in charge" or of his knowing how to be "in charge." A short time ago the bursting of a funnel-casing on board the finest and strongest ship that ever was built, on her trial trip, destroyed several lives and put several hundreds in jeopardy—not from any undetected flaw in her new and untried works—but from a tap being closed which ought not to have been closed—from what every child knows would make its mother's tea-kettle burst. And this simply because no one seemed to know what it is to be "in charge," or who was in charge. Nay more, the jury at the inquest actually altogether ignored the same, and apparently considered the tap "in charge," for they gave as a verdict "accidental death."

This is the meaning of the word, on a large scale. On a much smaller scale, it happened, a short time ago, that an insane person burnt herself slowly and intentionally to death, while in her doctor's charge and almost in her nurse's presence. Yet neither was considered "at all to blame." The very fact of the accident happening proves its own case. There is nothing more to be said. Either they did not know their business or they did not know how to perform it.

To be "in charge" is certainly not only to carry out the proper measures yourself but to see that every one else does so too; to see that no one either wilfully or ignorantly thwarts or prevents such measures. It is neither to do everything yourself nor to appoint a number of people to each duty, but to ensure that each does that duty to which he is appointed. This is the meaning which must be attached to the word by (above all) those "in charge" of sick, whether of numbers or of individuals, (and indeed I think it is with individual sick that it is least understood. One sick person is often waited on by four with less precision, and is really less cared for than ten who are waited on by one; or at least than 40 who are waited on by 4; and all for want of this one person "in charge.)"

It is often said that there are few good servants now: I say there are few good mistresses now. As the jury seems to have thought the tap was in charge of the ship's safety, so mistresses now seem to think the house is in charge of itself. They neither know how to give orders, nor how to teach their servants to obey orders—i.e. to obey intelligently, which is the real meaning of all discipline.

Again, people who are in charge often seem to have a pride in feeling that they will be "missed," that no one can understand or carry on their arrangements, their system, books, accounts, &c., but themselves. It seems to me that the pride is rather in carrying on a system, in keeping stores, closets, books, accounts, &c., so that any body can understand and carry them on—so that, in case of absence or illness, one can deliver every thing up to others and know that all will go on as usual, and that one shall never be missed.

Why hired nurses give so much trouble.

Note.—It is often complained, that professional nurses, brought into private families, in case of sickness, make themselves intolerable by "ordering about" the other servants, under plea of not neglecting the patient. Both things are true; the patient is often neglected, and the servants are often unfairly "put upon." But the fault is generally in the want of management of the head in charge. It is surely for her to arrange both that the nurse's place is, when necessary, supplemented, and that the patient is never neglected—things with a little management quite compatible, and indeed only attainable together. It is certainly not for the nurse to "order about" the servants.