TRAINING OF NURSES
1
734 mastectomy, simple mastectomy, irradiation, &c.-were equally effective, as measured by survival-rates, in spite of the fact that regional recurrences were less frequent in cases treated by radical mastectomy. The authors point out " that all methods of treatment may have been equally ineffective in prolonging life." N. E. MCKINNON. Department of Epidemiology and Biometrics, School of Hygiene, University of Toronto. SENSITIVITY TO ISOPRENALINE R. N. R. GRANT. ’ SiR,-I think it is worth while placing on record the case of a man of 54, with chronic asthma, who has become sensitive to isoprenaline. I started him on isoprenaline for his asthma in September, 1953, which gave him considerable relief. On Nov. 18, however, he sought advice because of a persistent sore mouth with redness and vesiculation,. particularly in the soft palate but involving also the whole buccal mucosa. It was estab- lished by repeated trial that this was undoubtedly due to tablets of isoprenaline sulphate, and he has been free from this trouble since stopping the tablets. TRAINING OF NURSES MATRON. SIR,-I agree with Dr. Findlay (Feb. 6) that there is need for radical changes in the nursing syllabus if we are to maintain an efficient and effective service in the future. Three main types of nursing staff are needed : (a) Highly intelligent, academic, and technically minded girls who will form the teams for specialist units-e.g., thoracic, neurological, and general operating in all types of hospitals. (b) Equally gifted but more socially minded women for ward sisters, suited to become the educators of families and patients, and able to cooperate with lay social workers. These nurses should become the key workers in every hospital and public-health department. (c) Semi-skilled, attendants forming perhaps 60% of the service. It used to be the practice-a wholly sound and sensible one, I think-to give these people only the simplest theoretical training. Many of them are still giving devoted service, but they are a dwindling band ; the truth is we are not replacing them, and, with an ageing population and the introduction of shorter duty hours, recruits are urgently needed. Can it be expected that any one syllabus would do for these three groups, any more than one would expect an industrial concern to train scientists, engineers, and factory hands as one group ? At present there are two main curricula : the basic general training with S.R.N. qualification ; and the assist- ant nurse course with s.E.A.N. status. The final result is that the academically minded girls who stay the course get into the specialist teams, but far too many of them are lost, because valuable specialised training is being given to too many people, most of whom are frankly bored with it, while the keen ones get side-tracked into taking more certificates, just to keep their wits sharpened. The second group are being offered many new incentives as industrial nurses and social workers, but most of them remain to form the solid core of the nursing service. The third group should, I think, have the opportunity to go straight on to the wards for the first six months of their training and then receive very simple instruction with a strictly practical bias, lectures and written work being reduced to a minimum. When I advertise for staff I always get replies from trainee assistant nurses ; and I always make a point of seeing them to find out why they will risk leaving the security of a hospital. Invariably, they say they are tired of the theoretical side of the work ; and many are the wrong type, but have been taken on because they have a pair of hands. In one hospital near my home, the assistant nurse trainees draw just a little over £7 monthly after all deductions ; this hospital has a costly training scheme, a permanent advertisement in the nursing press, and a chronic shortage of staff. Maybe this is an exception, but I doubt it. This whole question of nursing recruitment, selection, and training, is urgent. It would be a help if some simple psychological test could be applied to weed out the immature and the frankly hysterical, who because of their lack of staying power are costly, and who, if they do stay the course, do so at tremendous cost to them. selves and their patients. As for an overhaul of the whole syllabus, it would be interesting to know if Dr. Findlay has any definite scheme in mind. Would he have a basic training for all nurses, or two schemes with many modifications, as at present ? Lancashire. POLIOMYELITIS IN CHILDREN’S WARDS J. STEVENSON LOGAN Medical Officer of Health. SIR,—Dr. Ferguson (March 27) draws timely attention to the " increasing awareness of the connection between paralytic poliomyelitis and injections of all kinds." The interest and concern occasioned by evidence of association between immunising injections and paralytic polio- myelitis have perhaps lessened the attention which would otherwise have been paid to paralysis occurring in conjunction with other kinds of injection. Dr. Stanley Banks (Feb. 27) inculpates parenteral penicillin, and there is reason to believe that other injections may be fraught with comparable hazard. In 1952, an adult woman had facial palsy due to polio- myelitis ; a very short time before she became ill, she had had dental treatment involving injections on the same side. In 1953 Dr. J. K. Grant, medical officer of health for Great Yarmouth, informed me of a resident from this area, in whom poliomyelitis presented with a unilateral palatal palsy, shortly after dental treatment involving a maxillary injection on the same side. One is compelled to the conclusion that when polio- myelitis is prevalent in an area, it may be wise, particu- larly in dealing with children, to reserve injections for those conditions which are urgent, if there is no acceptable alternative to the intramuscular route for administering the therapeutic agent of choice. Southend-on-Sea. PATHOLOGISTS AND PNEUMOCONIOSIS SIR,-My letter of March 20 was not meant as a personal attack on Dr. Triger, but as a protest against all those who, without proof, assume greater accuracy and validity for one method of diagnosis than for another. Dr. Triger last week accuses me of the very assumption against which I was protesting. I did not claim that " clinical and radiological diagnosis of industrial dust disease is more reliable than post-mortem diagnosis," but only that the errors and validity of the former have been studied and that until pathologists have done the same they cannot play the role of assessors. It is interesting that while Professor Browne and Dr. Triger agree that the radiograph is a mere " shadow," they disagree as to the " substance " of the problem. The one (a clinician) holds to disability, the other (a patho- logist-clinician) to the post-mortem diagnosis. I certainly consider the function of the lungs in life more important than their appearance after death. We need to know much more about the effects of dust inhalation upon pulmonary function before we can really assess the incidence of " pulmonary dust disease "-a term that may have much wider implications than the present legal definition of pneumoconiosis. Meanwhile, we know that, in many cases, the " shadow " in the radiograph today may portend the " substance" of disability tomorrow, so it should not be ignored. Among many sources of sampling error in post-mortem statistics, the most important is the very one that Dr. Triger mentions in seeking to deny them ! Post-mortem
Transcript of TRAINING OF NURSES
734
mastectomy, simple mastectomy, irradiation, &c.-wereequally effective, as measured by survival-rates, in spiteof the fact that regional recurrences were less frequentin cases treated by radical mastectomy. The authorspoint out " that all methods of treatment may havebeen equally ineffective in prolonging life."
N. E. MCKINNON.Department of Epidemiology andBiometrics, School of Hygiene,
University of Toronto.
SENSITIVITY TO ISOPRENALINE
R. N. R. GRANT.
’
SiR,-I think it is worth while placing on record thecase of a man of 54, with chronic asthma, who hasbecome sensitive to isoprenaline. I started him on
isoprenaline for his asthma in September, 1953, which gavehim considerable relief. On Nov. 18, however, he soughtadvice because of a persistent sore mouth with rednessand vesiculation,. particularly in the soft palate but
involving also the whole buccal mucosa. It was estab-lished by repeated trial that this was undoubtedly dueto tablets of isoprenaline sulphate, and he has been freefrom this trouble since stopping the tablets.
TRAINING OF NURSES
MATRON.
SIR,-I agree with Dr. Findlay (Feb. 6) that there isneed for radical changes in the nursing syllabus if we areto maintain an efficient and effective service in the future.
Three main types of nursing staff are needed :(a) Highly intelligent, academic, and technically minded
girls who will form the teams for specialist units-e.g.,thoracic, neurological, and general operating in all types ofhospitals.
(b) Equally gifted but more socially minded women forward sisters, suited to become the educators of families andpatients, and able to cooperate with lay social workers. Thesenurses should become the key workers in every hospitaland public-health department.
(c) Semi-skilled, attendants forming perhaps 60% of theservice. It used to be the practice-a wholly sound and sensibleone, I think-to give these people only the simplest theoreticaltraining. Many of them are still giving devoted service, butthey are a dwindling band ; the truth is we are not replacingthem, and, with an ageing population and the introductionof shorter duty hours, recruits are urgently needed.
Can it be expected that any one syllabus would dofor these three groups, any more than one would expectan industrial concern to train scientists, engineers, andfactory hands as one group ?At present there are two main curricula : the basic
general training with S.R.N. qualification ; and the assist-ant nurse course with s.E.A.N. status. The final result isthat the academically minded girls who stay the courseget into the specialist teams, but far too many of themare lost, because valuable specialised training is beinggiven to too many people, most of whom are franklybored with it, while the keen ones get side-tracked intotaking more certificates, just to keep their wits sharpened.The second group are being offered many new incentivesas industrial nurses and social workers, but most of themremain to form the solid core of the nursing service.The third group should, I think, have the opportunityto go straight on to the wards for the first six months oftheir training and then receive very simple instructionwith a strictly practical bias, lectures and written workbeing reduced to a minimum.When I advertise for staff I always get replies from
trainee assistant nurses ; and I always make a point ofseeing them to find out why they will risk leaving thesecurity of a hospital. Invariably, they say they are tiredof the theoretical side of the work ; and many are thewrong type, but have been taken on because they havea pair of hands. In one hospital near my home, theassistant nurse trainees draw just a little over £7 monthlyafter all deductions ; this hospital has a costly trainingscheme, a permanent advertisement in the nursing press,
and a chronic shortage of staff. Maybe this is an
exception, but I doubt it.This whole question of nursing recruitment, selection,
and training, is urgent. It would be a help if some simplepsychological test could be applied to weed out theimmature and the frankly hysterical, who because oftheir lack of staying power are costly, and who, if theydo stay the course, do so at tremendous cost to them.selves and their patients. As for an overhaul of the wholesyllabus, it would be interesting to know if Dr. Findlayhas any definite scheme in mind. Would he have a basictraining for all nurses, or two schemes with manymodifications, as at present ?
Lancashire.
POLIOMYELITIS IN CHILDREN’S WARDS
J. STEVENSON LOGANMedical Officer of Health.
SIR,—Dr. Ferguson (March 27) draws timely attentionto the " increasing awareness of the connection betweenparalytic poliomyelitis and injections of all kinds." Theinterest and concern occasioned by evidence of associationbetween immunising injections and paralytic polio-myelitis have perhaps lessened the attention which wouldotherwise have been paid to paralysis occurring inconjunction with other kinds of injection.
Dr. Stanley Banks (Feb. 27) inculpates parenteralpenicillin, and there is reason to believe that other
injections may be fraught with comparable hazard. In1952, an adult woman had facial palsy due to polio-myelitis ; a very short time before she became ill, shehad had dental treatment involving injections on thesame side. In 1953 Dr. J. K. Grant, medical officer ofhealth for Great Yarmouth, informed me of a residentfrom this area, in whom poliomyelitis presented with aunilateral palatal palsy, shortly after dental treatmentinvolving a maxillary injection on the same side.
One is compelled to the conclusion that when polio-myelitis is prevalent in an area, it may be wise, particu-larly in dealing with children, to reserve injections forthose conditions which are urgent, if there is no acceptablealternative to the intramuscular route for administeringthe therapeutic agent of choice.
Southend-on-Sea.
PATHOLOGISTS AND PNEUMOCONIOSIS
SIR,-My letter of March 20 was not meant as a
personal attack on Dr. Triger, but as a protest against allthose who, without proof, assume greater accuracy andvalidity for one method of diagnosis than for another.Dr. Triger last week accuses me of the very assumptionagainst which I was protesting. I did not claim that" clinical and radiological diagnosis of industrial dustdisease is more reliable than post-mortem diagnosis," butonly that the errors and validity of the former have beenstudied and that until pathologists have done the samethey cannot play the role of assessors.
It is interesting that while Professor Browne andDr. Triger agree that the radiograph is a mere
" shadow,"they disagree as to the " substance " of the problem. Theone (a clinician) holds to disability, the other (a patho-logist-clinician) to the post-mortem diagnosis. I certainlyconsider the function of the lungs in life more importantthan their appearance after death. We need to knowmuch more about the effects of dust inhalation uponpulmonary function before we can really assess theincidence of " pulmonary dust disease "-a term that
may have much wider implications than the presentlegal definition of pneumoconiosis. Meanwhile, we knowthat, in many cases, the " shadow " in the radiographtoday may portend the " substance" of disabilitytomorrow, so it should not be ignored.Among many sources of sampling error in post-mortem
statistics, the most important is the very one that Dr.Triger mentions in seeking to deny them ! Post-mortem
