1 lesson on important points in hospital architecture. 2 lessons on methods of organization and obligations of different factors concerned in hospital management. 1 lesson on the superintendent's duties and his relation to each part of the institution.

1 lesson on the duties of the head of the training school. 1 lesson on training school blanks and records.

1 lesson on hospital income, its sources and methods of increasing it.

2 lessons on general business principles and methods.

4 lessons on hospital bookkeeping for small and mediumsized hospitals.

1 lesson on purchase of beds, bedding and ward furnishings. 1 lesson on the purchase of surgical supplies.

1 lesson on the purchase of drugs and management of drug

room.

1 lesson on purchase of rubber goods and special appliances. 1 lesson on purchase of coal, engineer's and laundry supplies.

1 lesson on the purchase of perishable food supplies.

1 lesson on the purchase of stock food supplies.

1 lesson on management of storeroom and accounting for supplies.

1 lesson on the theory of hospital kitchen management.

1 lesson on theory of laundry management.

1 lesson on purchase and management of hospital linen. supply.

1 lesson on servants, their duties, contracts and government. 1 lesson on hospital sanitation.

1 lesson on hospital statistics and the annual report.

In connection with this course it is suggested that pupils entering for the course on institutional management be given a term in the hospital office and admitting room; in the storerooms, kitchen, diet kitchen, office of training school principal, drug room and other departments of the hospital, and receive practical instruction regarding the practical running of each department.

SOME PROBLEMS OF THE TRAINING SCHOOL.*

MISS M. A. NUTTING,

Director Department of Hospital Economics, Teachers' College, Columbia University, N. Y. (By Invitation.)

It is not necessary before an audience of hospital workers to preface a discussion of the problems of the Training School with an account of the general system under which such schools are administered. You are all presumably familiar with it; but with the thought that there may possibly be those present who are not so informed, I will venture to speak briefly of the foundation on which the Training School rests and of the forces which control its activities.

Called into existence as a means of improving the care of the sick in hospitals, the first training schools, both in England and America, were established, not by the hospitals, but by groups of individuals outside of them who provided. funds for the maintenance of the schools, and entered into an agreement with the hospitals to give the pupils certain. definite teaching, training and experience in return for such services as they could render for the sick. Although entirely subordinate to the regulations of the hospital in that concerned their work, the pupils were nevertheless under the direction of an independent body in matters connected with their teaching, training, conduct and discipline.

In the first school for nurses (established in 1860 by the Nightingale Fund at St. Thomas's Hospital, London), this body, called a committee, so interpreted its functions that it not only paid for the board of the pupils and for their uniforms, but paid also a part of the salary of the ward head nurse, as compensation for her services in teaching the probationers. The committee went further, and paid a medical

*Read by Miss A. W. Goodrich.

instructor to give the pupils, "at the bedside," certain instruction "of a medical and surgical character."

It will thus be seen that the organization of these early nurses' schools was in some ways similar to that of the medical school, with this essential difference, however, that the medical student paid for his education and training, and the pupil nurse was paid to receive hers.

By just what process this training school committee was. eliminated, and the school absorbed entirely into the hospital, it matters little to discuss here. In the improved condition of the hospital brought about by the school; in the efficiency of this method of caring for the sick, and its comparatively low cost; in the obvious advantage to the hospital in having entire control of the pupils, and the ease with which such control could be secured, we find a situation leading readily to the incorporation of the training school into the hospital, and the practically universal assumption at a later date that the sick in the hospital can only be properly nursed by means of a training school. The logical outcome of this belief is expressed today in the thousand and more training schools which are an integral part of the hospitals in this country, and governed by the same authority.

In capacity, character and purposes these hospitals vary widely. There are the large general hospitals, of from two to three hundred to one thousand beds, amply provided with opportunities and material, and furnishing a suitable field for the training of pupils. There are the medium-sized hospitals of from fifty to one hundred beds, offering less in the way of opportunity, but well able to cover a considerable portion of the required ground; and there is a very large group of those which are still smaller, ranging from twenty-five to fifty beds, with diminishing powers and opportunities, so far as the training school is concerned; while beyond these lie the very small hospitals of five, six, eight and ten, up to sixteen beds, very greatly limited in ability, and offering as a rule a mere fraction of what is required as a field for the teaching and training of the nurse. Training schools are found in 53 hospitals of this description, while more than 500 of the entire 1,000 schools are in hospitals of 50 beds and under.

Of other types of hospitals, such as special, for diseases. of women or children, or for nervous disorders, and more

recently of hospitals or sanitaria for tuberculosis, the training school for nurses is a common feature; while in the strictly private hospital or sanitarium for paying patients (often, indeed usually, for the treatment of one special form of disease) the the nursing is frequently done largely by means of a school.

It needs no statement of mine to assure this audience that under any and all of the above conditions the school in its entirety has no life of its own, but is shaped and moulded to the needs of the hospital and restricted (?) by its powers. In numbers and character of pupils, in purpose and direction, in conditions of living quarters, food, recreation, in hours on duty and hours off, and finally, in teaching and in training throughout, in substance, method, teachers and equipment, the school takes what the hospital determines it shall have.

That several of our hospitals are governed in a liberal and enlightened spirit, and thought given to the welfare of the pupil nurse, is a matter quite irrelevant from the main issue, which is the position of the training school in its relation to the hospital. It stands unique as an education institution of high importance practically owned by another institution which profits by the industry of the pupils. Under good conditions the results may be good, often even excellent; under other conditions, they may be, and often are, unspeakably bad. Under any or all conditions the question to ask is, "Does this system produce the best results? Is it a just arrangement for hospital and pupil? Is it the best that we can do?" And the answer to this is that we do not know, because we have not as yet really tried any other.

In the meanwhile it is quitè certain that the present relation between hospital and training school gives rise to many and difficult problems, and it is perhaps not too much to say that the one person to whom these problems present themselves in their most pressing and perplexing aspects is the executive officer who represents both institutions and holds the double office of superintendent of nurses and principal of the training school. Deeply loyal to both, seeing clearly the needs of each, concerned in meeting them adequately and in carrying out the purposes of each to the fullest possible degree, wherever they conflict, she is between the upper and nether millstones.

Such a conflict appears at the very outset in the necessity which exists for selecting the pupils in accordance with the immediate needs of the hospital, rather than with suitable standards of requirement for the general work of nursing. Now, I know of no training school, large or small, where the number of properly qualified women applying for admission is large enough to meet the needs of the hospital, and by that I mean to do the actual nursing work in it.

Now, by properly qualified women I do not at all mean highly educated women (desirable as they are), nor do I set up any severe standard of requirements. I mean simply women of good, thorough English education, of suitable age, good character, physically and mentally sound, and temperamentally able to stand the strain of hospital training and the subsequent work into which that training leads. You will agree, I am sure, that nothing less than this is a safe foundation on which to build any professional or vocational training, yet out of the applicants to our training schools the number that fully meets these moderate requirements is small. A few in the more prominent schools exceed them, but I say without hesitation, as a result of many years of experience in a representative school, that, notwithstanding the fact that there may be hundreds of applicants each year, the number of those who are properly qualified falls considerably below the number of pupils needed by the hospital for its nursing service, even though such pupils may De occupied in it for nine, ten, eleven hours daily, and a good part of Sundays included. Now, because this small number of good (desirable?) and promising candidates cannot do the required work, it becomes necessary to add to it (to "keep up the numbers," as the phrase goes) by a larger or smaller number of others who fall below standards in varying ways and degrees, often very much below.

With what reluctance these doubtful candidates, sometimes too young, sometimes too old, frequently meagerly educated and quite too frequently badly brought up, irresponsible, unrefined-with what reluctance they are considered, admitted on probation, and finally, when it becomes quite impossible to meet the needs of the hospital and dare to send away even one more probationer, with what misgivings and regrets these doubtful sisters are at last accepted, enrolled and brought into the life and work of the school,