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Nursing in Workhouse Infirmaries N ightingale saw service to the ‘‘sick poor’’ as her main mission, and who better than the sick of the workhouses? For her the sick pauper was no longer a pauper, that is, someone deserving of harsh treatment, but a ‘‘fellow creature in suffering,’’ who deserved the best care.1 Her vision (shared with Dr Sutherland) that workhouse infirmaries could provide care as good as the bestnursed suburban hospitals has already been related in Public Health Care. Her goals for broad workhouse reform were effectively to abolish workhouses, by confining them to housing the able-bodied unemployed , roughly 10 percent of their usual population. For the rest, the aged, the sick, the disabled and the chronically ill, care in appropriate asylums was prescribed, for children schools and foster care. Nightingale ’s vision was in effect that of a modern social welfare system, with a range of supportive institutions, in place of workhouses, whose punitive regimes were intended to keep people off the public purse. The workhouses were institutions of the Poor Law, intended to provide only the most minimal care for the suffering and destitute. Traditionally , monasteries and convents had given care to the needy, and so when Henry VIII abolished them in the 1530s, an alternative had to be found. Parishes were given the responsibility for the poor and needy, but only had to supply sufficient support to ensure survival. More than that was to be avoided, as it was felt that able-bodied people on low wages would find it to their advantage to go on parish relief rather than work. The Poor Law was made harsher in 1834 by making ‘‘outdoor relief,’’ or food or money given people who stayed at home, more dif- ficult to obtain. The truly destitute would have to pass the ‘‘workhouse test,’’ which meant going into the workhouse rather than 1 In Public Health Care (6:338). / 577 starve. Small workhouses were amalgamated for efficiency of operation , becoming ‘‘union workhouses’’ or ‘‘parish unions.’’ The larger workhouses and unions included infirmaries, which provided the barest level of care to the sick. With no system of health insurance, and no regular state support for hospitals in Britain, the workhouse infirmaries became the ‘‘real hospitals’’ of the sick poor. Some poor had no choice, for hospitals normally charged fees. While there were charity wards and various other measures to widen access, most of the poor were still ineligible. Some sick poor would initially obtain admission to a regular hospital, but had to go to a workhouse infirmary when their savings were exhausted. In practice, there were five patients in a workhouse infirmary for every one in a regular hospital . Nightingale understood numbers and realized that the reform of the workhouse infirmaries was essential if real care were to be provided to the sick poor. A number of people were actively engaged in reforming nursing in hospitals, but no one had taken on the reform of the workhouse infirmaries. For reformers such as Louisa Twining, who formed a workhouse visiting society, the goal was the elimination of the worst abuses. Nightingale’s radical vision was of no less than the institution of patient care that was of equal quality to that in a regular hospital. Public Health Care relates Nightingale’s pioneering work to reform the workhouse infirmaries, beginning in Liverpool in 1864. Reform work began in London also in 1864, but this required new legislation and tax provisions, which were not passed until 1867. The key element to effect reform was the bringing in of trained, paid nurses to replace the ‘‘pauper nurses,’’ the untrained women inmates who were not themselves sick, and were notorious for stealing their patients’ food and gin. Since wages cost money, which had to be paid for by local taxes (the rates), there were enormous disincentives to hiring trained nurses. Nightingale argued both for the desirability (grounded on her Christian faith) and practicality (destitute inmates who got better could leave and get jobs). Nightingale considered the Liverpool Workhouse Infirmary a ‘‘great experiment,’’ with the potential for greater results than from ‘‘any other social reform at present on trial’’ (see p 586 below). She described the Liverpool Workhouse Infirmary as ‘‘the largest and most complicated mass of pauperism dealt with by one body.’’2 For 2 Note after 13 April 1868, Add Mss 47754 f183. 578 / Florence Nightingale: Extending Nursing this particular project...


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