Letter to Jane Senior
1873-10-18

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On "Memo. by Dr. Bridges" London Oct 18/73
The cases put are:
1. The Medical Officer is always there:
he is an educated man: and in many cases
the most able man of the set
Ergo make him supreme
2. The Governer/Master is always there: but he is not
necessarily a man of dufficient power or education
Ergo he cannot always be trusted with supreme
jurisdiction
3. The Committees are difficult to get together; and
in some cases cannot exercise supreme control.
[This is not however the cases at Highgate (Central London Sick Asylum Board)
and there are first rate men on the Committee or Board.]
Ergo they cannot be trusted.
Conclusion: that Matron & her Nurses must
virtually be under the Medical Officer:
an experiment which has been tried since Hospitals
began & has always ended ill, either for the
moral or the efficient element.
A Medical Officer has quite other things to do
than to be head of the Nurses -
A man can never govern women -
- No good ever came of Medical Officer doing Matron's duty.
- And even the efficient treatment of sick is thereby sacrificed.
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The fight has been fought our in Military
Hospitals since Military Hospitals existed:
owing to warning experience, the follwing
is how the system:
(1) At the Central Military Hospital ([illegible]), the Nursing
& the Nurses are obliged to do the bidding of the
Principal Medical Officer.
But he can't stope their beer if they don't -
(a notable expedint formerly adopted in India.)
The Matron (Sup.) only can do this: i.e. wield
discipline.
And there is a Governer over all -
with appeal in certain cases to the Secretary of State
(2) In another large Military Hospital
the Principal Medical Officer is also (unfortunately)
the Governer.
But precisely the same relation exists.
If in the case (1) the P.M.O got up a 'row' with the Matron (Supt.)
both sides could come before the Governer.
If in case (2) the P.M.O got up a 'row' with the Acting Supt.,
both could come before the P.M.O. as Govener,
with appeal in either case to the Secretary of State.
[N.B. I would observe that this anomalous stae of things (2)
is what it is sought to make law & system at the
Metropolitan Workhouse Imfirmaries
[illegible] the Matron & Med: Off: differ on a point of
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Nursing morality or discipline, or on what are the best
internal arrangements to carry out the Medical
Officer's orders, - (Which if she does not know
better than he does, she is not fit to be head
of the Nurses, & ought not to be there at all -
any more than he ought to be there; if she
knows Medical treatment better than he does -
(a thing which has happened)) -
then the Medical Officer & Matron go
before the Medical Officer as Supreme Head.
Is this administration? -]
II. As regards the application of this to
Metropolitan Workhouse Imfirmaries:
is it permissible that the whole administration
should be under the Medical Officer?
If he does his dury as  Governor,
must he not neglect his duty as Medical Officer?
[N.B. He is not like the Principal Medical
Officer at a Military Hospital:
he has to attend with one assistant
on 500 sick perhaps or more.]
Must there not be some supreme power
with appeal?
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And must not the Guardians (or their Committee)
be that supreme power?
And The Appeal Court the Local Government Board?
[N.B. if the Guardians won't attend or won't act,
Mr. Stansfeld can appoint, can he not? -
ex officio Guardians to watch over the interests
of the rate payers.] I may add that first-rate men won't
act: unless they have the power as well as the trouble: If the power is vested in
the Medical Officer & the L. Govt. Board, the best men will not serve as Guardians.
III. It would seem,
as if the application of this to Metropolitan
Workhouse Infirmaries, were: -
1. You must trust to your Committee of Managers
2. Your Steward must be their Officer
3. Your Medical Officer must be their Officer
4. Your Matron myst be their Officer.
5. If the Committee choose to appoint a
Governor - as in the case of Liverpool - to represent them, altho' under them, let them: [but don't let the Medical Officer
be implied Governor.]
6. If they appoint the Medical Officer as
Governor, let them do it subject to approval
as to administrative fitness by Local Govt. Board
- taking care however that the attention of the
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Medical Officer, withdrawn from the sick,
be supplied by additional mical assistance, and taking
care that duties, & authority of the Matron over the Nursing
Staff is properly defined
& guarded
7. As to the Nurses: -
They must be under the Matron.
They must be amenable to her along in discipline
and for the discharge of duties
subject to appeal to the Guardians or the Local Government Board thro' the Guardians,
- in the same cases in which, in Military Hospitals
Nurses have right of appeal to Secretary of State.
The Matron & Nurses must be obliged to obey
the professional orders of the Medical Officer:
Subject to complaint against Nurses solely to the
Matron: and against the Matron to the Managers
or through them
or to the President of the Loval Govt. Board.
(Such complaint to be transmitted through the
Committee or Guardians.)
The Matron must look to the Medical Officer
for professional instructions which she has to obbey:
but for nothign else.
She should be supreme over her Department, so long
as she discharges her duty & sees that her
Nurses discharge theirs - is not she?
She loses her supremacy only when she
neglects her duty or fails to see that her Nurses
discharge theirs: and this only
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until the complaint is investigated; (&
appealed about to the Local Government Board
if thought necessary).
The Matron must be admitted, censured, &
suspended by the Managers; & if discharged soley by the
sanction of the Local Govt. Bd.
Liverpool Workhouse case
I might say that it is because the Governor
& not the Medical Officer: the Governor "who
"is supreme over the whole Establishment",
Medical Officers & all: that it "works harmoniously"
And the "Hospital Committee" is the real
practical head of the "Lady Supt." - (her
real masters, as they ought to be -) & not
the Governor.
The Medical Officer at Liverpool Workhouse
has no administrative authority whatever
over the Nursing Staff.
And when there was a bad Governor, we know the result to
poor Agnes Jones - the first Lady Supt., who died there.
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But I should prefer to add: that the success
of a great & hazardous experiment at
Liverpool was due mainly to self-devotion,
to forbearance, to sinking personality in work
- to the good wishes of the Committee - to the
action of good men & true privately -
Mr. Rathbone, Mr. Cropper, & the like - xx
& not to any law or Regulation -
that there was in fact no ground on which
to rest either
& that this example shows clearly that not
much can be expected if a cut & dry
plan is laid before Boards of Guardians
to make or to mar - can it? -
"make slow haste".
Better to get it done & a tradition
introduced at one place at a time.
is it not?
xx There are equally good men at Highgate (Central London
Sick Asylum Board) - Mr. Wyatt, a prince of men:
Sir Sydney Waterlow etc. etc. -
but will these men "come when you do call for them", if you
don't give them power?
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 IV. On the "Certificate" question: (viz. to Nurses leaving)
It does not appear to be quite understood that
it is because "Medical Officers" & ex-"Matrons"
& all sorts of people give Testimonials
(& these T.s. are taken) that the mischief arises.
The rule at one great "Sick Asylum": an excellent
rule: was that the Manager's stamp should
be put on all Testimonials recieved or given.
[but how if other "Sick Asylums" will accept
Testimonials without the stamp - - - - ?]
At that very Asylum, upon a Nurse being dismissed,
very properly, by the Matron for insubordination,
the "Medical Officer" (whose Certificate it is now
proposed to take) and the ex-Matron gave the
Nurse such excellent ? "Testimonials" that she
was immediately taken on at higher wages
at another "Sick Asylum".
As for asking "Medical Officer" as to "Nursing
efficiency" - how can the Matron be the "head of
the Nurses", "the head of her own Department"
if this be done? - If the Matron is not directly responsible
for carrying out the directions of the Medical Officer, -
if the Matron is not the best judge of her Nurses'
nursing, she had better not be there at all.
And we had better give up trained nursing Matrons, &
revert to the old Housekeeping Matrons: the
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decayed cousins of some green-grocer Guardians.
[I have known - & not once only - a Nurse
of my own receive an excellent Testimonial
from the very Doctor, an excellent man,
upon whose report I had (rightfully)
dismissed her.]
And it may be added with at least equal truth as
what has been said of good men acting as Guardians:
- that you cannot get education women, gentlewomen,
trained Matrons, to act; if they have not the
power given them to fulfil their responsibility, - if they are
not really the Nursing heads thay have been
trained to be: And that successful Medical treatment
depends mainly upon successful organization of Nursing.
If however the Local Government Board
object to the War Office plan,
would not the best way about Certificates be
to prevent their issue altogether,
& for some authority, say the Board of Guardians, to grant a statement of Services
only on the application of persons wishing to
employ the Nurse?
[One does not give certificates to servants to hawk
about.]
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V. On the "duties" question: (Dr. Bridges' proposed "letter")
If the above pages be at all acknowledged as true,
must not these "duties" be recast?
Will all that mixing up on authorities & "aidings"
do?
Is not the first thing they wanted:
a common-sense set of rules
putting every body's saddle on every body's
own back?
At present they have one saddle for the
whole household: and it is expected that
every one will put it on when so disposed.
Is it possible to ingraft a really good
Nursing system on these Rules?
Do as you will - will not every body with
any authority interfere with Matron & Nurses?
If the President does not see his way to
alter this - would it not be better that
he should, by attacking the enemy in detail
& carrying one fort after another - introduce
the Nursing element completely & successfully?
Florence Nightingale