ADDRESS ON THE Duties and Conduct of Nurses in Private Nursing. BY WILLIAM L. RICHARDSON, M.D. ADDRESS ON THE Duties and Conduct of Nurses in Private Nursing. Delivered at the Boston Training School for Nurses, June 18, 1886. BY WILLIAM L. RICHARDSON, M.D.„ Visiting Physician of the Massachusetts General Hospital. Printed at the request of the Directors of the Boston Training School for Nurses attached to the Massachusetts General Hospital. BOSTON: PRESS OF GEO. H. ELLIS, 141 FRANKLIN STREET. 1887. ADDRESS. All the great wars of modern times have, in more ways than one, marked eras of progress in the world’s history; and the historian’s record will show, when the final balance is struck, that much good has resulted from what at first oftentimes seemed only evil. This Training School in Boston, for ex-1 ample, is one of the direct outgrowths of the Crimean war. Returning from the East, where she had been able to see the practical value of her early training at Kaiserwerth, laden with the rich experience which she had acquired during her grand service in the Crimea, Miss Florence Nightingale started, in June, i860, the first English training-school for nurses, and, in fact, the second such school in the world. The medical profes- sion at once recognized the value of the institution, and wel- comed with open arms the graduates of the training-school connected with St. Thomas Hospital. The Sarah Gamps of the sick-room began rapidly to disappear. The need of trained! nurses, as thus demonstrated in London under the teaching of Miss Nightingale, was at once felt; and, in 1873, this train- ing-school, that connected with the Bellevue Hospital in New York, and the Connecticut training-school in New Haven, were opened. The value of these institutions to the community as well as to the profession was soon recognized; and to-day there are, in this country alone, more than thirty such training- schools. 4 A new field for women has thus been opened, and yet the supply of graduates from well-organized training-schools still falls far short of the demand. There were in Boston, May 13, 1886, one hundred and sixty-three trained nurses registered at the Registry in Boylston Place ; and yet, on that day, wishing to obtain the services of one of these nurses, I found that there were but ten disengaged, and several of these had only just reported for duty. Nor was this experience an exceptional one. While the supply in our own city falls far short of the demand, many of the cities of this country have no supply at all, and applications are constantly being received even here for nurses to go and settle in this or that city of the Union. The possession of a diploma from any first-class training- school is a guarantee that the graduate can earn, if she chooses so to do, an honest and honorable livelihood. When, as time goes on, the supply comes more nearly to equal the demand, the public and the profession will be able to exercise more1 choice in the matter; and then the best nurses will come to the front. This school will soon find itself in more marked com- petition with other schools. The aim of the directors must therefore be to graduate the best possible nurses. With that end in view, changes in the course and methods of instruction are constantly being introduced. Every endeavor is being made to give our students the best education that can be given. Among these changes is the introduction of a closing lecture, to be given each year by some member of the Hospital Staff, on the duties and conduct of nurses in private practice. It is to the consideration of this subject that I now invite your attention. Before considering the character of your work after you graduate, I cannot let this opportunity pass without advising you to consider well, before you go any further, whether nurs- 5 ing is your vocation. In this Hospital where everything is systematized, and you have only to fulfil certain routine duties under the supervision of those who for the time being are your teachers, and where your shortcomings are viewed by friendly eyes it is not at all a difficult matter for you so to conduct yourselves, during your stay, as to be able to obtain a diploma at the completion of the prescribed course of study. Outside this Hospital, when you come to enter the field of private practice, you will find everything greatly changed. You will then be thrown upon your own resources ; and your critics will be the public, who have no friendly interest in you, and whose verdict will depend solely on the character of your work. The competition in that field is open to all, and the best ones win. Now, unless you have a real interest in your work, unless nurs- ing has in itself an attraction for you, failure awaits you, though you have a diploma from a dozen training-schools. It is far better for you to stop now rather than to go on and attempt success in a work for which you have no fondness, and which is merely a matter of pecuniary recompense. The stu- dent who enters the medical school simply because he wishes to be a professional man is always a failure. The nurse whose heart is not in her work is destined to pass many a weary hour learning a lesson which a little forethought would have taught her to avoid. It is far better, therefore, early to recognize the’ fact that nursing is not your vocation, and to withdraw from a competitive contest in which you are sure, when perhaps it is too late, to be doomed to disappointment. The mere facT that you have been able to go through a training-school will not of itself make you a successful nurse; and I would ear-, nestly advise you now not to adopt nursing as your profession, unless you mean to achieve for yourself success. Let your aim be to become the best nurse in the city in which you mean to 6 practise ; but you can never become that, unless you love the work which the profession of nursing demands. Do not be content to be a second-rate nurse. If you are clearly persuaded that you have a fondness for this work, then go on and use every opportunity while in this school thoroughly to fit yourself for the duties which await you after graduation. Nursing is no easy work, and you will find two years a short time in which to acquire all the knowledge and experience which it will be necessary for you to have when you start out to meet the varied calls which will be made upon you. You must work hard, first thoroughly to master the principles which lie at the basis of all successful nursing, and that can be done only by hard study; and, in the second place, you must learn how intelligently to observe what is going on about you, in order to acquire that invaluable knowledge which can be gained only by experience. The training-school offers you an opportunity to obtain an education which will fit you to take a front rank in the corps of trained nurses who are doing good service in this country. Whether you take that front rank or not is a question the solution of which depends only on yourselves. Training- schools can offer instruction and the opportunities to learn by practical experience how to use that instruction. It must, however, depend on the student herself whether she will so. acquire the necessary knowledge, and will so learn by that ex- perience, as to fit herself for the every-day work of her chosen vocation. Natural ability and a so-called gift for nursing count, of course, a good deal at the start; but the more I see of life, and the more I study the causes of this one’s success or that one’s failure, the more I am persuaded that, with very rare exceptions, earnest, steady work and a determined application to one’s chosen vocation count, in the long run, far more than any so-called genius or inherited talent. 7 During your stay in the school, endeavor to learn all you can from the text-books which you study and the lectures which you attend,— not as a mere matter of memory,— but in such a way as to make your knowledge become as it were a part of your- self, just as you have become so familiar with the multiplication table that you know the results, though unconscious of the process by which those results are obtained. Never content yourselves with learning rules. Try always to ascertain the reasons for the rules. By so doing, you will come to under- stand the principles on which all rules are founded. The nurse who is satisfied to do what she is told to do, without endeavoring to ascertain why she does this or that, becomes only a piece of imitative machinery, of little value in the sick- room, where she finds herself thrown upon her own resources and amid circumstances which constantly differ from those with which she has become familiar in a hospital, where much that is done becomes necessarily a matter of routine. In this Hos- pital, for example, there are many preparations used under names never known outside of the walls of this building. The composition of these you should understand, in order that you may know how to use the same agents when you meet them under other names and in different combinations. Accustom yourselves always to observe patients carefully,— their symptoms and their appearance. During my connection with this training-school, I have been frequently struck by a marked difference in nurses as regards this special qualifica- tion. One nurse contents herself with carrying out the orders of the physician; while another, equally faithful in that respect, also renders invaluable assistance by the intelligent report which she is able to give of the patient’s condition during the interval since the last visit of the physician. At the last quar- terly examination, one of the pupils had been in this training- 8 school so short a time that it seemed unfair to ask the questions which an examiner might naturally ask; and I, therefore, con- tented myself with inquiring of her what kind of cases she had seen, and what symptoms she had noticed as belonging to this or that disease. Her answers, based wholly on her observa- tion, would have done credit to a nurse passing her final exam- ination. She was interested in her work, and, unconsciously to herself probably, had yet so watched her patients that the information she had gained would have been of the greatest service to the physician in attendance. By thus mastering the principles on which all nursing is founded, and by carefully observing what is going on around you, in order that you may make the most of the extensive and varied material which is to be found in the wards of this Hospital, you will be enabled to leave this school with honor to yourself, and fully prepared to ■enter the field of private practice with no fear of the result. In that field, you will find that the circumstances are greatly altered, and that new duties and responsibilities await you. You will be then thrown upon your own resources. You will be among strangers, often exacting and inconsiderate ; with no head nurse ready at hand and willing to help you in your difficulties; with no house-officers to question, and under the observation and exposed to the criticism of physicians with whose manners and ways you are unacquainted. The whole situation is changed. It will be my endeavor to give you some advice, which I hope may prove of service in aiding you to perform your duties and shape your conduct in this field of private nursing on which you are to enter when you leave this school. f Your Duties to the Registry.— Most of you will settle in large cities; and, in all of these, you will find a Registry for Nurses. The establishment of such registries soon followed, as a matter 9 of course, the opening of training-schools. They have proved of great service to the public, to the profession, and to the nurses. At any hour of the day or night a trained nurse can be obtained at almost a moment’s notice. Be sure, therefore, to aid the Registry by promptly reporting the moment you are engaged, in order that no second messenger be despatched for you, only to find that you have already responded to some other call. When ready for duty, again report, and, having reported, remain at your residence; or, when absent from it, either from necessity or pleasure, leave word where you can be found or at what hour you will return. See to it, also, that you do return at the hour appointed. In this way only can the service of the Registry be made acceptable to the public and the profession, upon which it must of necessity depend for its support. Lin the Household.— You alone are responsible for the manage- ent of the sick-room and the care of the patient. If you feel yourself to be master of the situation, the family will always acknowledge and recognize your right to command. On your first arrival, however, do not be in a hurry to enter on the duties of your position. As a rule, friends do not like to give up the care of one who is dear to them to a stranger; nor is the patient anxious for such a change. It is, therefore, no more than natural that they should be at first eager to wait upon the patient, and jealous of any assumption of authority on your part. A little tact, however, a little patience, and a will- ingness to assist when wanted, rather than hastily to usurp a place which both the family and the patient wish should be filled by friends, will soon right everything. They will not be slow to see, nor the patient long in recognizing, that your training has fitted you to perform the duties better, to render little services in a more acceptable way, than those whose only qualification is their friendship and willingness to perform duties with which they are unfamiliar. Always, therefore, enteri on your new office quietly, as one who is willing to assist, and! not as though you were a trained professional who had come/ to usurp the place of those who are only too anxious to adminis- ter to the wants of the patient. Familiarize yourself as soon as possible with the ways of the household of which, for the time being, you are to be a member. Accommodate yourself at once to their ways, and do not expect that the established routine of their daily life is to be changed to meet your peculiar ideas. Eventually you will find that the arrangements will of necessity be changed to suit the condition of things; and, with a little tact on your part, you will be able to make such sug- gestions as will not only render your position an agreeable one, but will also conduce to the comfort and welfare of your pa- tient. At first, the household arrangements are necessarily disturbed by the advent of sickness; and it is not unreasonable that the family should think more of the patient or even of themselves than of your personal comfort. In a few days, however, the machinery will soon adapt itself to the altered condition of affairs. Whenever you have any fault to find with the domestic arrangements of a house in which you may be nursing, speak of it, at a suitable time, to whoever may be the head of the household, and to that person alone. If the fault be not corrected, speak of it at a proper and convenient time to the family physician, who will, if the complaint be a reason- able one, see that the trouble is remedied. Be especially careful as regards your relations with the ser- vants. They will naturally look upon you as an interloper, and iview every action on your part with a jealous eye. Do not therefore make any unnecessary work for them, nor expect them to wait upon you. If you have occasion to go into the 11 kitchen for any purpose, make friends with the cook, who will usually be found in an aggressive mood, but who can be very easily persuaded to be your friend; and, as a rule, you will find her the best friend you can have in the house. If you want her to do anything for you or your patient, ask her pleasantly; for what can be secured grudgingly as a right can often be ob- tained, when asked for pleasantly, as a favor. Never assume an air of superiority when dealing with the servants; but, on the other hand, never be too familiar with them. At best, they recognize your superior position unwillingly; therefore, do all that you can to conciliate them. Never repeat in the kitchen what you may have learned upstairs. Whenever you have occasion to meet the servants, have always a pleasant word, answer their proper inquiries about the patient, and do not let them for a moment imagine that you consider yourself any better than they consider themselves. Never allow yourself to indulge in any criticism with the servants on the domestic arrangements; for you may rest assured that, if you do, such fault-finding, on your part, will very soon be reported to the family. Will you eat in the kitchen with the servants? If the family, are wise, you will never be asked to do so. A nurse who, of ne- cessity, is thus forced into intimate relations with the servants, cannot, without offending them, remain loyal to the family and be silent downstairs as regards affairs which may be happening: abovA It may, however, happen that, owing to circumstances,; no other arrangement can conveniently be made. If that is the case, I would certainly advise you to accept pleasantly the posi- tion. It is very easy subsequently to explain the disagreeable situation to the physician; and, if possible, he will see that a different arrangement is quietly made. Sympathize, so far as you can, with the family, and remem- 12 ber the great mental strain under which they are laboring. Should the case terminate fatally, do all that you can to shield them from the distressing incidents which may attend the final scene and the subsequent necessary arrangement and dispo- sition of the body. It is often after death has taken place that you are able to render your best service to the family, and one that will subsequently be the longest remembered and most appreciated. Do not assume a patronizing air toward the mem- bers of the family; but, always remembering their anxiety, do all that you can to cheer them up. Be careful not to have con- fidential talks with the physician, the nature of which you afterward endeavor to surround with mystery. Be thoughtful of the welfare of the other members of the household, as well as of the patient, and see that they get the rest and exercise which they need, but which unconsciously, in the excitement, they are so apt to forget to take. You may be sure that such little acts of thoughtfulness and kindness to them on your part will never pass unnoticed. Do not have a prescribed line of duties be- yond which you are unwilling to go. It should be a nurse’s aim to do whatever can be done to comfort or relieve her pa- tient, to assist the physician, and to help the family, without stopping to consider whether the work to be done is strictly in the line of her special professional duty. The most popular physicians are those who, when sickness comes upon a house- hold, at once do all they can to lighten the burden and aid and comfort the family, even though by so doing they render ser- vices which could never be strictly called professional. As the result of a somewhat varied experience, I must frankly say that I have found physicians always ready to help in time of trouble where nurses are only too apt to content themselves with per- forming their own specific duties. There are, of course, excep- tions to this rule; and such nurses are invaluable, and there- fore rarely to be obtained. 13 Never receive callers except such as come on purely business purposes, and then let the call be as brief as possible. Be care- ful not to allow any duties or pleasures outside of the house in which you are engaged to interfere in the slightest degree with your duties to the patient, whose comfort or even safety is con- fided to your care. Should any sudden emergency arise which would interfere with some personal plan of your own, never com- municate such a disturbance to the patient or the household but, like a good physician, see your best pre-arranged plans upset without any apparent loss of temper or even annoyance. During your service in a household, you must of necessity come into confidential relations with its members. You are forced to a certain degree to learn their secrets, and in many cases to see the skeletons in their closets. When your work is done, and you leave to go to other families, never be unfaithful to the confidence which, willingly or unwillingly, has been placed in you. Never therefore repeat to others, and often to willing ears, facts which you have acquired in the discharge of your duties. When a nurse leaves a house, she should leave behind her all knowledge of what has occurred within its walls. There are many people who are only too glad to find out all that can be learned about the affairs of others, but a nurse should be the last one to gratify a morbid though almost uni- , versal curiosity. In the Sick-room.— In the sick-room be always cheerful, even though the case be hopeless, and the prognosis admit of no honest doubt. In the household, however, let your cheerful- ness be of the kind that does not deceive. Do not mislead the family by assuming a hopefulness that is not warranted by the nature of the case or the condition of the patient. Outside of the sick-room, be perfectly frank and outspoken. It is far bet- ter that those friends who have the most at stake should know 14 the truth, rather than be deceived by misleading statements and the holding out of unwarranted expectations, until, when the end comes, they are forced to meet an unexpected issue for which they were unprepared. Patients are often unduly alarmed about themselves, and suspicious that they have not been told the worst about their own condition. Be careful, therefore, never to appear mysterious in what you are doing, and never to whisper in the sick-room,— a fault which many people have, and which is sure to awaken in the minds of nervous patients suspicion that something is going wrong. A nurse should always be neat and tidy in her personal appearance, and dress in a quiet and becoming manner. Whether she will wear the cap and apron of the hospital is purely a matter of taste, al- though I must myself confess to a strong liking for them ; and in that preference, I think, most physicians would agree with me. Jewelry is as much out of place in a sick-room as rus- tling dresses or squeaky boots. Absolute cleanliness in the sick-room is of the first importance; and a nurse should always see to it that no fault is ever found with her in that respect. The room should always be kept tidy; and, if possible, all medicines and the attendant paraphernalia should be kept out of sight of the patient, in an adjoining room. There, also, everything should be kept clean and orderly; and glasses, spoons, etc., should be washed as soon as used, and placed ready for the time when they may be again needed. The ven- tilation of the sick-room should ever be uppermost in the nurse’s mind ; and she should remember that a thermometer merely records the temperature, and not the pureness, of the air in the sick-chamber. Remaining as she must constantly in the room, a nurse often becomes oblivious of the fact that the air has become foul until her attention is called to it by the physician, who, entering from the fresh air outside, at once 15 detects the unsanitary condition of the room. Her manner in the sick-room should be always quiet and gentle. There is rarely any need of haste, and a nurse who does her work with- out confusion or bustle unconsciously gives to the patient a quiet calmness which many a nurse fails to secure through her own lack of the necessary repose of manner so essential in a good nurse. Anticipate, so far as is possible, the wants of your patient, but at the same time do not be too officious. A nurse who is always trying to do something prevents the patient from obtaining the very quiet and rest which he may so much need. Be careful that others do not thoughtlessly talk in the sick- room in a way that must of necessity disturb the sufferer, who, however, may not be walling to find fault with an annoyance from which you should shield him. Never under any circum- stances relate your experiences. Educated in a hospital and familiar with the daily incidents of surgical and medical wards, nurses are apt to forget that, to the laity unaccustomed to such scenes, their description is disagreeable and often painful. It is certainly very questionable taste that would allow a nurse to talk of her cases in the presence of one who is sick himself. As a rule, a nurse should not talk at all in the sick-room. If the patient wishes to talk, and there is nothing in the nature of the case to contraindicate it, of course the nurse may endeavor to take her part in the conversation ; but the patient should lead the way. No greater nuisance exists in the sick-room than a talkative nurse. When members of the family come into the room, the nurse, unless her duties detain her, should always retire to an adjoining room, where she can easily be called, and where her presence will not interfere with any private conversa- tion which the family may wish to indulge in. Never repeat startling or unwelcome news in the sick-room, nor permit the patient for a moment to believe that anything is amiss in the 16 household arrangements. He should never be allowed to have his thoughts occupied or disturbed by any events which are occurring outside of his chamber. Any pleasant news or pleas- ing bit of gossip may be told him, if he is in a condition to enjoy its recital. He should, however, never be informed of any jars or disturbances in the household machinery; nor should he be made acquainted with any of your own little per- sonal discomforts or grievances. , Should any emergency arise, keep cool and think twice be- fore you act. Never show by your manner that you are in doubt about what should be done. If you are calm and quiet, every one will follow your lead; but, if you for the moment lose your head, a panic in the sick-room, and even in the house- hold, is inevitable. Under such circumstances, do not do any- thing for the simple reason that you feel you must do something. Quietly make up your mind as to what the trouble is, and what is the best thing to do, and then, and not before, do it. Sub- sequently, when the doctor arrives, you will be able to give him a reason for your action. It is in emergencies that the best results of your hospital training and study are seen. If, then, you are obliged to stop and try to remember what the books said or what you have been taught in the hospital, you may be sure you will find yourself of little value in the household that looks to you in such a crisis for leadership. It is then that you want to understand the principles, and not have to attempt to remember the rules which govern nursing. If you have mas- tered the former, your common sense will suggest the latter. To the Physician.— Always be loyal to the physician under whose advice you are acting. Disloyalty to him, on your part, only creates doubt of his skill in the minds of the household, adding thereby to the existing mental anxiety of the family, and possibly awakens distrust in the mind of the patient. 17 Never, therefore, question the wisdom of his directions, the correctness of his diagnosis, nor institute comparisons between his methods of procedure and that of other physicians under whom you may have served, and for whom you may justly or unjustly have far greater respect. Never, by your manner or your conversation, suggest a consultation. The very suggestion implies a doubt in the attending physician, which you should be the last to originate. Remember that he, and not you, is responsible for the suc- cessful management of the case, and that, as a rule, his opin- ion, based on a much wider range of experience than your own, is entitled to much greater weight. Nurses are very apt to consider that their studies and training fit them to be as capa- ble of forming a correct opinion of a case as the education and experience of a trained physician. No greater mistake could be made. The family do not engage you as the physi- cian any more than they expect the physician to be able to per- form the duties which only a nurse can properly do. The medical profession is now open to women, and the Massachusetts Medical Society has announced its willingness to receive among its members women who are able to pass the same examination by its Board of Censors as is required of men. Without expressing any opinion of the ultimate result of such a change or of the wisdom of women entering the profession, I would urge upon you to remember that, when engaged in the care of a case, your services are required as nurse, and not as physician. If you decide to enter the med- ical profession, you are then the physician, and not the nurse. Do not attempt to be both. It is not necessary, on the other hand, to be mysteriously taciturn, and decline to allude in any way to the case. A little tact will enable you so to express yourselves as to be non-committal on the important questions of diagnosis, prognosis, and treatment. 18 Always be ready, so far as the conditions of the case will permit, for the expected visits of the physician; and be present during his visits to answer such inquiries as he may wish to make, or to inform him of such changes in the patient’s condi- tion or symptoms as may have occurred during his absence. Should it happen that an unfavorable change has taken place, either manage to inform him of the fact before he sees the patient or make a written record of the same, which can be quietly handed to him when he comes into the sick-chamber. Never allude to anything unfavorable in the course of the case in the presence of the patient. Keep an accurate record of the temperature, pulse, and, if need be, of the respiration; of the dejections and of any other facts which may be of importance as a contribution to the clinical history of the case. Carry out the orders of the physi- cian ; and, in every way possible, see that his ideas as to the treatment are enforced. No orders can be properly carried out that are not thoroughly understood. Therefore, understand clearly his wishes and the orders which you are to see properly executed. These orders may include something which is new to you, and the exact nature of which you do not understand. If such is the case, always ask him, before he leaves the house, for fuller instructions or explanations. Never be too experi- enced in your own conceit or too old to learn ; and one learns only by admitting ignorance. It is better for the patient, fairer to yourself as well as to the doctor, that you ask for further instructions rather than that you go blindly on and err through an unwillingness to acknowledge your ignorance or lack of experience. The best doctors, as well as the best nurses, are those who are always asking questions. The poorest doctors, as well as the poorest nurses, are those who know everything and have no need of further instruction. 19 Should any change take place in the condition of the patient which might require an immediate alteration in the treatment, quietly send word to the physician, informing him by a note what the nature of the change is. He is then able to send you word what is to be done, or to come and see the patient, if he thinks a visit necessary. Never, however, let the patient know that you have noticed any such change, or that you have deemed it advisable to notify the physician. You may have been needlessly alarmed, and it should be your aim never to convey that alarm to the patient. When the physician ar- rives, it is a very easy matter to inform him that the patient does not know that he has been summoned. When operations are to be performed, be careful and have all the necessary preparations made beforehand; and, in mak- ing your arrangements, consider well what emergencies may arise during the operation, and prepare also for those. Do not, however, make these preparations in the sick-room itself, if they can possibly be made elsewhere. Always inform the physician privately of any facts which you may learn, accidentally or otherwise, which might throw any light on the case. Report also to the physician at a proper time any disobedience to his orders of which the patient or the patient’s friends may have been guilty. Such information a doctor will always consider as confidential; and, as such, he will act upon it, without, however, betraying the source whence his information came. If the condition of the patient warrants it, always manage to leave him for a few moments alone with the doctor. It not unfrequently happens that the patient is anxious to tell the physician something which he might not be willing even the nurse should hear. A momentary absence from the sick-room, therefore, gives him an opportunity to make any statement which your presence might render impos- sible. 20 It is a great temptation to a nurse to desire to impress a doctor with her knowledge. Not content with reporting facts to him, she is often anxious to add her opinions on the case, and even to suggest plans of treatment such as she may have seen used elsewhere. The object she hopes to gain is twofold, — the effect on the doctor and also on the patient, to whom she has probably ventilated those opinions before the arrival of the physician. What error can be more stupid ? The doc- tor will of necessity be prejudiced against the nurse, even though her suggestions be valuable. In fact, his prejudice will usually be in a ratio corresponding to the merit of those sug- gestions. To quote cases and their treatment to the physician in attendance is a sure method of securing his adverse criti- cism. Very few physicians take kindly to the suggestions of a nurse, especially if made in the presence of the patient. On the other hand, it not unfrequently happens that you are able privately to hint to the doctor how the mind of the patient or his family is acting, and thus render him a good service which he is not likely to forget. To Each Other.— If you would make other people respect the profession which you have chosen, respect it yourself, and do all that lies in your power to elevate it. Never allow your- self to criticise another nurse; and, when those among whom you may be placed indulge in such criticism, do not be too willing to join with them in condemning one about whom you really know nothing. Defend those who are absent and can- not defend themselves. Criticisms or slurs upon another nurse will, in the long run, hurt you in the mind of outsiders more than it will the object of such criticism. If, for any reason, you are called upon to succeed a nurse who may have been dismissed or been obliged by circumstances to leave, never make remarks derogatory to your predecessor. 21 Do not by word or manner imply that your ways are better than her ways, or throw out hints that her duties have not been properly performed. Quietly perform your own duties, without attempting to disparage the way in which she may have per- formed hers. It not unfrequently happens that, as a case develops, the assistance of a second nurse is required. When she arrives, do all in your power to make her feel at home. Quietly, and at a convenient time, explain to her the nature of the case, and, unless the physician chooses to interfere, arrange with her as to how the duties are to be divided between you. As a rule, it is better for you to take the day, leaving the night service for her, so arranging your hours of duty that you are in charge both at the morning and evening visit of the physician. When the time comes for you to go off duty, report to your successor any changes that may have taken place in the condition of the patient, and leave in writing the physician’s orders for the night, so that, in case of a mistake, there may be no misunder- standing as to which nurse was responsible for the error. When you come on duty again in the morning, learn from the night nurse any facts which may be of importance and about which the physician will be likely to inquire. If your services are required as the second nurse in such a case, be loyal to the nurse who has already had the care of it, and under whom you will be called upon to serve. Do not attempt to impress upon the family your superiority by throwing out hints as to her standing, proficiency, or care of the patient. Nurses should always consider themselves as members of a grand sisterhood, and be ever ready to defend each other; for one never knows when they themselves may need defence. Nothing has struck me more in my connection with this training-school and the Harvard Medical School than the striking difference between 22 the students of the two institutions. In the Medical School there is a spirit of clanship and good fellowship, and for a student, to use a popular phrase, to “ go back on ” another student is almost unheard of; while here, and especially in private practice, it is rare to find a nurse who will shield another who has made a mistake, or who will not in one way or another endeavor to impress upon the family, the patient, or the medical attendant her own superiority. To Yourself.— In your efforts faithfully to perform your duties to your patients, never forget your duties to yourself. The preservation of your own health is of nearly as much im- portance to your patient as it is to yourself. Be sure that you have sufficient food, exercise, and rest. The meals may not be served at fixed times, nor be of just that variety or kind which suits your peculiar taste, but see to it that you have enough to eat, and at reasonable hours. Take regular exercise whenever you can do it, without neglecting a duty suddenly imposed upon you by some exceptional emergency. See to it that you are allowed sufficient time for rest, and so educate yourself that, when you work, you work, and, when you rest, you rest. Naps at irregular intervals are of no use to a nurse who would work faithfully for her patient. A nurse should lay out her work so systematically as to obtain a certain share of the twenty-four hours for perfect and uninterrupted rest. Emergencies may arise at any time which will interfere with these plans for your regular rest, diet, or exercise. Such interferences are to be expected, and no complaint on your part should ever be made of the temporary inconvenience or even discomfort they may occasion. The majority of those who employ trained nurses are apt to forget that the faithful discharge of the duties of the sick-room by a competent nurse is, at the best, a severe strain on her physical health. A nurse, however, who properly asks 23 for a reasonable consideration as to hours for rest and exercise, will rarely be refused. Should you find that the family are not considerate of your welfare, a word to the physician will usu- ally be all that is needed to secure a proper regard for your health and strength. Always bear in mind that it is the part of prudence to “ make hay while the sun shines ”; and it is well, while one has health and strength, to regularly lay aside a certain portion of one’s earnings against the time when sickness or accident may incapacitate one for work. The constant increase in the amount deposited by a nurse in a reliable Savings Bank attests more her common sense than a foolish expenditure for dress and extravagances, which can only excite unfavorable comment. Conscious yourselves of the grand service which a corps of trained nurses can render in a community, there is no need for me to extol the high calling which you have chosen to follow. All I have to do is to urge upon each of you to strive for distinction. With that end in view, study hard while in this school; observe intelligently all that is going on about you; ask for information on all subjects which you do not thoroughly understand; ascertain the principles which lie at the bottom of all nursing; learn the reason for all rules and for all that you do. In private practice, make yourself one of the household ; be considerate in your treatment of the servants ; sympathizing with the family and thoughtful of their wishes; gentle and watchful in your care of the patient; loyal to the physician; true to yourself and the sisterhood of which you are a member. Working thus in this school, with such an aim in view, and in your private practice governed by such motives, you need have no fear of the result. You cannot fail of success, nor of winning the lasting esteem, respect, and friendship of all with whom you may be brought in contact.