History of Nursing in Pacific Canada

Report of proceedings of the annual convention of the British Columbia Hospitals' Association. British Columbia Hospitals' Association 1930

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 ♦; llr oceeUmgs♦ ♦
of the
Cfjirteentf) Annual Contention
of the
British Columbia
Hospitals* Association
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VANCOUVER, B.C.
August 19th to 22nd. 1930
HOTEL VANCOUVER  TABLE OF CONTENTS
Page
Officers and Executive, British Columbia Hospitals' Association      1
Officers and Directors, Western Hospital Association      2
Officers and Trustees, Northwest Hospital Association      3
List of Exhibitors ..      3
TUESDAY MORNING, AUGUST 19, 1930
Opening of the Thirteenth Annual Convention, B. C. Hospitals' Association, and Joint Meeting with the Western
and Northwest Hospital Associations      4
Addresses of Welcome: His Worship, Mayor Malkin      4
Mr. Geo. Walkem, M.L.A      5
Presidential Addresses: Mr. J. H. McVety, President British
Columbia Hospitals' Association....     6
Mr. G. W. Olson,   First Vice-President Western Hospital Association   10
Appointment of Committees     14
TUESDAY AFTERNOON
Address—"Financing of Hospitals in British Columbia"—
Dr. H. E. Young    15
Address—"The Ratio of Hospital Personnel to Patients"—
Dr. Malcolm T. MacEachern    22
Address—"The Hospital, the Doctor and the Patient—The
Function and Responsibility of 'the Hospital in This
Triumvirate"—Dr. Howard H. Johnson    47
Address—"The Relationship of the Medical Profession to
the Hospital"—Dr. G. Harvey Agnew    51
Address—"Hospital Publicity and Community Relations—A
Better Understanding"—Mr. Matthew 0. Foley     58
TUESDAY EVENING
Dinner, Address and Presentation     62
WEDNESDAY MORNING, AUGUST 20, 1930
ROUND TABLE—"Nursing Section"
Topic—"The   Changing   Nursing  Era"—Miss   Carolyn  E.
Davis     63
Discussion      67 TABLE OF CONTENTS—Continued
'M^jtv Page
Topic—"Should  the  Small Hospital  Conduct  a  Training
School"—Miss Clara E. Jackson    70
Discussion     78
Topic—"Affiliation of the Small Schools of Nurses With the
Larger Schools"—Miss Helen Randal    79
Discussion     82
Topic—"Nursing Education"—Sister John Gabriel     84
Topic—"University Courses for Nurses"—Miss   Mabel   F.
Gray     89
Topic—"Dietetic Courses for Nurses—Miss Grace M. Fairley    93
WEDNESDAY AFTERNOON
ROUND TABLE—"Dietetic Section"
Topic—"Nutrition With Reference   to   the   Philosophy of
Life"—Dr. H. W. Hill     96
Topic—"Some   of  the   Newer   Phases   of   Nutrition"—Dr.
Martha Koehne...    96
Topic—"Preservation   of  Fresh  Food   by  Freezing"—Mr.
Harry R. Beard     97
Topic"Food Costs and Food Buying"—Mr. G. W. Olson  104
Topic—"The  Canadian  Meat  Inspection   System"—Mr. J.
G. Jervis  107
THURSDAY MORNING, AUGUST 21, 1930
ROUND TABLE—"Women's Auxiliaries and Social Service"
Report—"The Activities of the Auxiliaries of the British
Columbia Hospitals"—Summarized Reports  113
Topic—"The Value of a Women's Auxiliary to a Hospital"
—Miss Grace M. Fairley  119
Discussion  121
Topic—"The Value of a Social Service Department to a
Hospital"—Miss Amelia Feary  122
Topic"Functions   of   the  Hospital   Social   Worker"—Miss
Elizabeth McKinley  124
Discussion  127 TABLE OF CONTENTS—Continued
Page
GENERAL SESSION
Address—"Effect   of   State Health Insurance on Hospital
Finances and Economies"—Mr. C. H. Gibbons  128
Address—"The Forgotten Room"—Dr. G. A. Ootmar  136
THURSDAY AFTERNOON
Address—"The Value of Physical Therapy—Organization
and Management of a Department in a Hospital"—Dr.
Geo. A. Greaves  141
Discussion  147
Address—"Community Relationships of a General Hospital
—How Developed and How Sustained"—Miss Alice
G. Henninger  148
Address—"Libraries and Hospitals"—Dr. Helen G. Stewart 153
Address—"Some of the Newer Developments in Hospital
Equipment and Procedure"—Miss Kathryn K. Meitzler.. 160
"Question Box"—Conducted by Dr. M. T. MacEachern  163
FRIDAY MORNING, AUGUST 22, 1930
"Question Box" (Continued)  170
General Sessions—Resolutions  174
Business Session, 'and Election of Officers—Western Hospital
Association   177
Business Session, Election of Officers, and Resolutions—
British Columbia Hospitals' Association  178
Adjournment  181
Constitution and By-Laws, B. C. Hospitals' Association  182
Places of Meeting and Past Presidents  187
Public Hospitals in British Columbia  188
Provincial Hospitals  191
Licensed Private Hospitals in British Columbia  192
Registration—1930 Convention  194  BRITISH COLUMBIA HOSPITALS' ASSOCIATION
OFFICERS AND EXECUTIVE COMMITTEE
FOR THE YEAR 1930-31
Honorary President:  HON. S. L. HOWE, Provincial Secretary, Vietoria,
B. C.
Honorary Life Members:  DR.  M.  T. MacEACHERN, M.D., CM., D.Sc,
Associate  Director,   American   College   of  Surgeons  and  Director   of
Hospital Activities, 40 East Street, Chicago.
MR. J. J. BANFIELD, 327 Seymour Street, Vancouver, B. C.
President:  MR. J.  H.  McVETY, 411  Dunsmuir  Street, Vancouver, B.  C.
First Vice-President: MR. J. M. COADY, 553 Granville Street, Vancouver,
B. C.
Second  Vice-President:   DR.   E.   M.   PEARSE,  Provincial   Royal  Jubilee
Hospital, Victoria, B. C.
Treasurer: MISS G. M. CTJRRIE, North Vancouver Hospital, North Vancouver, B. C.
Secretary: MISS M. F. GRAY, Dept.  of Nuraing and Health, University
of British Columbia, Vancouver, B. C.
REGIONAL REPRESENTATIVES
Vancouver Island: MR. A. P. GLEN, Ladysmith General Hospital, Ladysmith, V. I.
Vancouver: MR. GEORGE HADDON, Business Executive, Vancouver General Hospital, Vancouver.
Coast Mainland: MR. G. W. MARSHALL, North Vancouver.
Fraser Valley: MR. R. C. McCULLOCH, Abbotsford.
Yale-Cariboo:   MR.  M.  L.  GRIMMETT, Merritt.
Okanagan: MR. W. B. HUGHES-GAMES, Kelowna General Hospital,
Kelowna,
Kootenay West: MR. COZIER, Kamloops.
Kootenay East: SISTER MARY CLARISSA, Superintendent, St. Eugene-
Hospital, Cranbrook.
Grand Trunk: MISS J. A. HARRISON, Prince Rupert Hospital, Prince
Rupert, B. C.
CONVENERS  OF STANDING   COMMITTEES
Medical Affairs: DR. R. A. SEYMOUR, Vancouver General Hospital,
Vancouver, B. C.
Business Affairs: MR. GEO. McGREGOR, 612 Humboldt Street, Victoria,
B. C.
Nursing Affairs: MISS BESSIE CLARK, Royal Columbia Hospital, New
Westminster, B. C.
Constitution and By-laws: MR. E. S. WITHERS, Royal Columbian Hospital, New Westminster, B. C.
Women's Auxiliaries: MRS. A. C. WILKES, St. Paul's Hospital, Vancouver, B. C. WESTERN HOSPITAL ASSOCIATION
OFFICERS AND DIRECTORS FOR THE YEAR 1930-31
Honorary President: MALCOLM T. MacEACHERN, M.D., CM., D.Sc,
Chicago, Associate Director, American College oft Surgeons and Director of Hospital Activities.
Honorary Vice-President: EMILY L. LOVERIDGE, R.N., Superintendent
Emeritus Good Samaritan Hospital, Portland, Oregon.
President: G. W. OLSON, Superintendent, California Hospital, Los Angeles,
California.
First Vice-President: J. H. McVETY, President, British Columbia Hospital Association, Vancouver, B. C
Second Vice-President: HOWARD H. JOHNSON, M.D., F.A.C.S., Superintendent, St. Luke's Hospital, San Francisco, California.
Third Vice-President: ALICE G. HENNINGER, R.N., Superintendent,
Pasadena  Hospital,  Pasadena,  California.
Secretary: GRACE PHELPS, RJST., Superintendent, Doernbecher Memorial
Hospital  for  Children, Portland,  Oregon.
Treasurer: ELLARD L. SLACK, Superintendent, Samuel Merritt Hospital,
Oakland, California.
DIRECTORS
MRS.  LOLA      M.  ARMSTRONG,  Editor Western  Hospital  Review,  Los
Angeles, California.
R. D. BRISBANE, Superintendent Sutter Hospital, Sacramento, Calif.
B. W. BLACK, M.D., Superintendent, Highland Hospital, Oakland, Calif.
G.    W.    CURTIS,     Superintendent,    Santa   Barbara    Cottage   Hospital,
Santa Barbara, California.
CAROLYN   E.   DAVIS,   R.N.,   Superintendent,   Good  Samaritan   Hospital,
Portland, Oregon.
SISTER JOHN GABRIEL, Seattle, Washington.
A. M. GREEN, D.D., Superintendent, Emanuel Hospital, Portland, Oregon.
GEORGE HADDON, Business Executive, Vancouver General Hospital,
Vancouver, British Columbia.
A. C JENSON, Superintendent, Fairmont Hospital, San Leando, Calif.
R. W.  NELSON, Superintendent, Portland  Sanitarium, Portland,  Oregon.
EMILY PINE,  R.N.,   Superintendent,  St.  Luke's Hospital,  Boise,  Idaho.
W. W. RAWSON, Superintendent, Thos. Dee Memorial Hospital Oeden.
Utah. '     *      '
J. 0. SEXSON, Superintendent, Good Samaritan Hospital, Phoenix, Ariz.
PRESTON T. SLAYBACK, Business Executive, Orthopedic Hospital School,
Los Angeles, California.
ROBERT WARNER, M.D., Superintendent, Deaconess Hospital, Spokane.
Wash. NORTHWEST HOSPITAL ASSOCIATION
OFFICERS AND TRUSTEES FOR THE YEAR 1930-31
President:  MISS CAROLYN E. DAVIS, Portland, Oregon.
First Vice-President:  MISS GRACE PHELPS, Portland, Oregon.
Second Vice-President: MISS MAY LOOMIS, Seattle, Washington.
Secretary:  MRS.  CECIL TRACY SPRY,  Taeoma,  Washington.
Treasurer:  REV. AXEL M. GREEN, Portland, Oregon.
TRUSTEES
MISS EMILY LOVERIDGE, Portland, Oregon.
MR. C J. CUMMINGS, Taeoma, Washington.
MISS MAY LOOMIS, Seattle, Washington.
MISS  GRACE PHELPS, Portland,  Oregon.
MR. C. W. FORDE, Jr., Longview.
SISTER PATRICK, Taeoma, Washington.
MISS ADAH PATTERSON, Seattle, Washington.
EXHIBITORS
Commercial Houses Displaying Exhibits:
B. C. Stevens Company Ltd., Vancouver.
Canadian General Electric Co., Vancouver.
Canadian Surgical Supplies Ltd., Vancouver.
Fisher and Burpe Ltd., Vancouver.
Hygiene Products Ltd., Vancouver.
Johnson and Johnson Ltd., Montreal.
Nutradiet Company, Seattle.
Victor X-Ray Corporation, Vancouver.
Institutions Presenting Educational Exhibits:
Provincial Mental Hospital, Essondale.
Provincial Laboratory, Kelowna.
Tranquille Sanatorium, Tranquille.
Vancouver General Hospital Laboratories. REPORT   OF   PROCEEDINGS
TUESDAY MORNING SESSION
August 19th, 1930
PRESIDING OFFICERS:
M>.  J.  H.  McVety, President British  Columbia Hospitals' Association.
Mr. G. W. Olson, First Vice-President Western Hospital
Association.
The Convention was called to order at 10 A.M. by Mr. J. H.
McVety, the Invocation was read by Venerable F. C. C. Heath-
cote, Vancouver, Archdeacon, Diocese of New Westminster, and
a prayer was offered by Monseigneur MacDonald, V.G., of Vancouver. The Chairman then introduced His Worship Mayor W.
H. Malkin of Vancouver, who gave the following address of
welcome to the delegates:
MAYOR MALKIN: Mr. Chairman, Ladies and Gentlemen: It
gives me great pleasure, on behalf of the citizens of Vancouver,
to welcome such an important Convention as this is to-day; important for the fact that you represent a profession that looks
after the most important thing in life, and that is health. Therefore there could not be a more important Convention held in the
City of Vancouver and I welcome you heartily from that standpoint alone if there were not any other reasons why I should
express a welcome to you. I suppose these Conventions are particularly necessary because I notice that in the profession of
medicine there is perhaps more change and more flux going on
than in any other profession in the world, outside of the engineering profession. I read the other day there were no less
than 2000 medical journals and periodicals published every week
or every month and that shows what a change is going on and
how much there is to learn about medicine. I should imagine
that the profession of doctor keeps a man awake more than any
other profession, outside of a lawyer. I shall not say anything
more. I welcome you here to Vancouver and leave with you the
keys of the City and I would like to particularly welcome our
friends who have come from below the 49th parallel. I think
one of the great values of these Conventions is their international
character, that you below this line and we above it may from
a Convention of this kind, go home with a friendly feeling to
each other. We must never forget this, that we as Canadian are
the interpreters of the British Empire to the United States and
we are also the interpreters of the United States to the British
Empire. Canada stands between the two, and therefore these
Conventions, comprising, as they do, Americans and Britishers, *^-
have not only the advantage of discussing the things that are
common to you, but they have the added advantage of developing a co-operative good-will spirit between the two great
branches of the Anglo-Saxon race. If we can only have that
good feeling between these two branches we need have no fear
for the peace of the world. I trust your Convention will be very
profitable not only in comparing notes that will help you to
understand your own professional duties better, but as I said
before, in creating that spirit of goodwill and co-operation which
is so necessary between our two great races.
CHAIRMAN: The Premier of this Province, the Honourable S.
F. Tolmie, is in Ottawa and therefore cannot be present at this
Convention, but has delegated Mr. George A. Walkem, M.L'.A.,
who is also a Director of the Vancouver General Hospital, to
represent the government of the Province of British Columbia
at this Convention.
MR. WALKEM: Mr. President, Ladies and Gentlemen: Might
I first express to this gathering the regrets of the Prime Minister. As your Chairman has told you, he had to go to Ottawa
and he left here last Friday night. The Provincial Secretary,
the Honourable S. TJ. Howe, also asked me to express his regrets
at his inability to be present. Your Chairman will tell you that
the Provincial Secretaries of the Province of British Columbia
have been proverbially generous to hospitals in this Province,
and the Honourable S. L. Howe is no exception. We have found
our Government very sympathetic to our requests for aid for
hospital purposes and the Honourable Mr. Howe has followed
in the footsteps of his predecessors.
I understand that this Convention represents not only the
British Columbia Hospitals' Association, but our friends from
across the line from the Pacific Coast States, and to you, on behalf of the Premier and the Provincial Secretary, I extend an
especially warm welcome. You know we have had a Commission here working on a report for the Provincial Government,
City authorities and the hospials generally throughout the Province. The report is very comprehensive and no doubt your deliberations will centre around that report, and I have no doubt
that some of the recommendations contained in it will be of very
great help to this gathering. The members of this Commission
were very eminent men in their line and there is only one recommendation, in that report that I do not agree with. Your President does not agree with it and I am also quite sure you will not
adopt it, and that is the recommendation that if candidates for
Directors are rejected by the Governors that they be not appointed by some other body.   I have a very keen feeling that this should not be adopted and perhaps Mr. McVety, your Chairman, will tell you why.
Now, Ladies and Gentlemen, I hope your deliberations will
result in much that is good. I hope that you will enjoy every
minute of your time and I would say to the Ladies and Gentlemen from below the line and to those from districts outside of
Vancouver, we are looking forward to another visit from you,
either collectively or singly, and we shall be very glad indeed
to see you at any time you choose to come.
CHAIRMAN: Before our speakers at this morning's session
leave, I wish to thank His Worship Mayor W. H. Malkin, Archdeacon F. C. C. Heathcote, Father MacDonald and Mr. George
A. Walkem for their kindness in coming here this morning.
I shall now present my report as President of the British
Columbia Hospitals' Association:
PRESIDENT'S REPORT
In welcoming the delegates to the Thirteenth Annual Convention, the Executive Committee desires to include also the
members of the Western and North Western Associations who
are meeting jointly with us for the first time. In addition it
may also be said that this is the first time that a joint meeting
has been.held of hospital associations of Canada and the United
States. Organized primarily for the advancement of knowledge
and to provide improved facilities for the care of the sick, the
associations are non-political and non-sectarian, which permits
of community service of a high order and ensures the careful
consideration of public authorities of all recommendation arising out of the deliberations of the delegates. The suggestion of
this joint meeting originated with Dr. F. C. Bell, Chairman of
our Program Committee for many years and President of the
Western Hospital Association. We greatly regret that a critical
illness has prevented him carrying on his work on the program
and his work was taken over by Mr. Geo. Haddon, a former president of the British Columbia Association, who, with the assistance of Dr. M. T. MacEachern, M. C. W. Olson, and many others,
has prepared a program which is submitted with confidence by
the Executive Committee for your approval. The success of the
convention has been materially assisted by the Hon. S. L. Howe,
Provincial Secretary, on behalf of the Provincial Government,
and by the Mayor and Council of the City of Vancouver, for
which the Committee desires to express its thanks.
The Year's Work
The Executive Committee held several meeting during the
year and dealt with a variety of questions of interest to the hos-
6 pitals of the Province, among them being: the cost of alcohol,
State Health Insurance, the use of nitro-cellulose film in X-ray
Work, Workmen's Compensation Board matters, and on the more
important issues kept the affiliated hospitals informed by circular letters.
The Purchase of Alcohol
Reference was made in the report for 1929 to a decision requiring hospitals to purchase grain alcohol exclusively from
liquor vendors, which resulted in an increase of approximately
400 per cent in the price of this commodity. The question was
taken up with the Provincial Secretary, who advised that an
amendment to the Liquor Control Act would require to be made
to change the procedure of purchase or to fix a price below the
standard on alcohol sold to hospitals. The Act was amended in
March, 1930, by the addition of a section as follows:
" (2) The Government may from time to time fix the
special price at which pure grain alcohol may be sold to institutions regularly conducted as hospitals, for consumption
only in such hospitals; and may also fix the special price at
which pure grain alcohol may be sold to The University of
British Columbia for use for scientific purposes. Hospitals
entitled to purchase pure grain alcohol at the price so fixed
shall be only such hospitals as are in receipt of Government
aid."
The Executive Council on April 30th, 1930, passed an Order-
in-Council fixing a rate of 25 per cent below the list price, the
Order reading in part as follows:
"The price at which pure grain alcohol shall be sold to
institutions regularly conducted as hospitals for consumption only in such hospitals, and to the University of British
Columbia for use for scientific purposes, shall be the same
as are shown in Price List No. 1 of the Liquor Control Board,
and subject to a discount of 25 per centum thereof."
This order, after allowing for the 99 per cent refund obtainable from the Dominion Government on the Excise Tax, reduced
the net price to approximately $5.93 per gallon. It was the view
of the Executive Committee that this price, although a material
reduction, was considerably in excess of the cost, plus a small
charge for handling, and the question was further taken up with
the Provincial Secretary with the result that another Order-in-
Council was passed on June 11th, 1930, as follows:
"THAT, under the provisions of the 'Government
Liquor Act,' chapter 146, of the 'Revised Statutes of British
Columbia, 1924," Price List No. 8, as approved by Order- in-Council No. 525, dated April 30th, 1930, be amended by
striking out all the words after the word 'purposes' in said
Price List and substituting in lieu thereof the following
words, namely:
'shall be at the rate of $19.46 per gallon.' "
This Order further reduced the price to $4.58 per gallon, but
unless the distillers have made a substantial increase in the price,
the Liquor Control Board is making a very heavy charge for
handling. It is the intention of the Committee to discuss this
question with the new Board as soon after it is constituted as
possible.
Nitro-Cellulose Film
During the year the Committee has co-operated with the
Provincial Fire Marshal in the reduction and elimination of fire
hazards in hospitals, more particularly in connection with the
use and storage of nitro-cellulose film. The report of Mr. J. A.
Thomas for 1929 deals with this work and is reprinted for your
information:
"Public and Private Hospitals—Co-operating with the
Department of the Honourable Provincial Secretary, a close
check has been kept on all hospitals throughout the Province. Orders for alterations and improvements of conditions
were issued and enforced where such were necessary. Owing
to the tragedy that occurred in a clinic at Cleveland, Ohio,
U. S. A., where over one hundred persons lost their lives as
a result of inhaling the gases of burning nitro-cellulose film
used for X-ray purposes, a prompt survey of our hospitals
and clinics in this Province was at once made. The conditions under which nitro-cellulose X-ray film was stored and
used were found to be exceedingly dangerous. Acting on
your instructions, I proceeded to Ottawa, where a conference had been arranged by the Canadian Fire Marshals to
discuss the question of the best method of preventing such
a catastrophe in our Canadian hospitals. Attending and
addressing this conference were a number of the leading
radiologists and experts on nitro-cellulose film in Canada
and the United States. As a result of attending this meeting
I was in a position on my return to inaugurate an educational campaign among the hospitals in this Province with
a view to providing for the safe-keeping of the nitro-cellulose film in use and to arrange for the use of the acetate
safety-film in the future. In carrying out this work I was
ably assisted by Mr. J. H. McVety, president of the British
Columbia Hospitals' Board, and members of the Executive,
and by Drs. F. C. Bell and H. Mcintosh of the staff of the
8 Vancouver General Hospital. Without the co-operation and
advice of these men my work along these lines would not
have been so successful as it proved to be. I am glad to
report that to-day over 95 per cent of our hospitals and
clinics are using the acetate safety-film, and that in the very
near future the use of the nitro-cellulose film for X-ray purposes will be entirely prohibited in this Province."
State Health Insurance
A progress report on this subject was submitted by the Commission appointed by the Legislature and through the courtesy
of the Provincial Secretary sufficient copies were secured to
supply all of the affiliated hospitals.
Since this report was distributed the Commission has resumed hearings. The Association was represented by the President and Vice-President Coady. It was their view that the
scheme, when adopted, should be unlimited and not restricted,
as suggested by some representatives of interested organizations,
to persons receiving small salaries or incomes. As the cost can
only be determined after the basic principles are decided upon
and the Commission has not yet submitted its final report, it is
impossible to deal with the subject more definitely. The delegates are, fortunately, to hear an address on the subject by Mr.
C. H. Gibbons, Secretary of the Commission, and he, no doubt,
through his close association with the subject and the Commissioners, will disclose to some extent the nature of the Commission's views, insofar as they have taken form.
Hospital Survey of Lower Mainland
Due to heavy pressure on the existing hospital facilities in
Vancouver and vicinity it was considered necessary to obtain
a report from outstanding hospital authorities regarding the sufficiency of the facilities provided and recommendations for the
future growth and development of this important branch of
community life. After an enlargement of the original terms of
reference the Provincial Government joined with the City of
Vancouver and appointed A. K. Haywood, M.B. (Tor.), M.R.C.S.,
L.R.C.P. (Lond.) (Chairman), Malcolm T .MacEachern, M.D.,
CM., D.Sc, and William H. Walsh, MM. (Secretary), as Commissioners to make a . survey, the terms of reference being as
follows:
(1) A survey of the hospital facilities of Greater Vancouver
as to how adequately they are meeting the present needs,
and the determining of future lines of development and
policies for the next fifteen to twenty years.
(2) A survey of the administration of the Vancouver Gen- eral Hospital as to how adequately it is meeting present
needs, and its adjustment to future requirements.
(3) An analysis of the factors that enter into the per capita
cost of the Vancouver General Hospital to its patients, and
a comparison of the various items of expense with the operating costs of other hospitals.
(4) In general, the Commission is instructed to make a survey of the services provided in Greater Vancouver for the
institutional care of disease, and of the development and
maintenance of these, now and for the future.
(5) In making this survey, the Commission is called upon
to especially consider the relationship of the Vancouver
General Hospital to the broad question of such services, and
to study particularly the facilities which it affords, and the
manner in which these are administered and financed.
After an exhaustive enquiry the Commission submitted a
final report on April 25, 1930, in which they dealt comprehensively with many questions of interest to larger hospitals. Arrangements have been made to supply hospitals of 100 beds or
over with copies of this report.
In conclusion, may I take this opportunity of thanking those
who have done so much to make the Association a success and
particularly those who have come long distances to assist in
making the present convention the most instructive and interesting in the hospital history of the Province of British Columbia.
Respectfully submitted on behalf of the Execuitive Committee,
JAS. H. McVETY, President.
CHAIRMAN: I shall now call upon Mr. George W. Olson, First
Vice-president of the Western Hospital Association and Superintendent, California Hospital, Los Angeles, California. This is
the first occasion on which there has been a joint meeting of
the B. C. Hospitals' Association and the Western Hospital Association and these sessions are under the joint chairmanship of
Mr. Olson and myself.
MR. OLSON: President McVety, Honored Guests of this Convention, Members and Delegates of the Convention of the Associations here represented: I am exceedingly happy to be privileged to be present at this convention. I want to qualify that
by saying I am not so happy over the fact that I am here carrying out the duty and responsibility of a Joint Presiding Officer.
That is rather a source or cause for regret. At the annual meeting of the Western Hospital Association in Portland last October, I was unable to be present, and one of my colleagues took
10 advantage of my absence and had me elected as one of the Vice-
presidents, but they were wise enough to elect a man for president whom they knew to be capable of performing the duties
of that office. When I learned the results of the election and
found out that Dr. F. C. Bell, the director of the great Vancouver General Hospital had been chosen president it pleased
me very much, particularly because it emphasized the international character of the Western Hospital Association. When it
was decided to have the convention in Vancouver under Dr.
Bell's chairmanship, we were very happy and since that time I
have been looking forward with delight to the opportunity which
I felt would then be afforded to me to come so far north to meet
the hospital workers from this section of our great American
continent. We know no lines of nationality or allegiance to
government when it comes to performing our duty to the sick.
We are all animated by a spirit which is not derived from any
political government or authority — even greater than that —
in the spirit of Christ, to go forward into this work in our individual institutions and even more so when we come together
in this Inter-State and International Conferences in that spirit,
and I am sure you are all animated with the same noble motives
in coming to this meeting. Now in the selection of its president,
any association naturally takes its best man. That rule, however, is often disregarded when it comes to picking its vice-
presidents and so I appear before you in the position of vice-
president, and through the play of fate, have been thrown into
the position of responsibility of having to function in the place
of the best man of the Association, chosen to preside over it
during the past year and over this convention, and that it is
an unfortunate thing for you as well as for me. I wan to compliment Mr. McVety here, on behalf of the Western Hospital
Association for the work he has done in the local arrangements
and in preparing the programme, and more particularly in his
selection of the convener of the programme Committee, Mr.
George Haddon, who as soon as this work was placed upon
him, immediately brought forces together which have resulted
in the programme which is now in your hands. I want to say
that having had for the last twenty years experience in many
associations, large and small, that the programme before you is
as varied and as interesting a contribution as any hospital programme I have ever seen.
Now, in addressing you for the President of the Western
Hospital Association, it should be my duty to give a review of
the work of the organization during the past year and probably indicate some of its policies for the future, but due to the
unfortunate circumstances, which I have already related, and
11 as I was not picked for any such duty and am not prepared
for it, I am not in a position to do either, for which I am sorry.
The Western Hospital Association is a conference of an educational character, between the hospitals of the Pacific States
and of the Western provinces of the Canadian Dominion. We
do not pretend to exercise any administrative function or to
influence administration from a governmental or municipal
standpoint in the sphere in which we labor. It is a conference
in which we get together for educational purposes, exchanging
notes, opinions and experiences, and drawing inspiration from
one another. Now we from the States are particularly profited
and benefitted by having the opportunity to mingle with you
from the Dominion of Canada, because you have here a hospital
system somewhat different from our own. My personal opinion
is that your provinces and dominion have been wise in not engaging in the operation of State or Municipal Hospitals but leaving this to the voluntary enterprise of charitable institutions
and good citizens in your respective communities. In our States
we have a dual system. There the municipalities endeavor to
conduct hospitals in the respective counties or cities and run them
on a scale befitting the type of patient for which they are intended, namely, the poor and most indigent in the community.
Alongside of that, charitable institutions have bound themselves
together in various associations for the conduct and operation of
so-called voluntary hospitals where individual benevolence and
philanthropy is given an opportunity to manifest itself. We
have such hospitals conducted by the various religious organizations, Episcopalian, Methodist, Presbyterian, Lutheran, and first
and foremost the Catholic Sisterhoods who probably in the States
conduct as many hospitals as all of the other religious organizations combined. These institutions are for the middle class
and better class—better in so far that they can afford better
accommodation for themselves; but they are also for the poorer
class, and we are striving in these municipalities to put more
and more of the poorer class of people in, because our people,
all of them, prefer to come to our hospitals because the entering into our hospitals does not mark them as indigents or paupers. Entering the municipal hospital does, because one of the
requirements of admission is, that you must be practically penniless or without means to pay for your care before you can get
in. To me that has always been more or less of an abhorrence.
We should have municipal hospitals of such a type that they
should be run on a standard that would satisfy every one, or
else we should not have them at all. My preference is for your
system where the government, and the municipalities encourage
and aid in supporting the voluntary hospitals which are directed
12 and managed by people who do it for the love of the thing and
because in their hearts they have a desire to help their fellow-
man. The problem in the United States remains to be worked
out. In some States the hospitals are indirectly subsidized to
some extent, by exemption from taxation. This is not the case
in California but we are going to change that law in California
and next November there is a measure going before the legislature which we hope will exempt us from taxation. We hope
California will come into line with the other 45 States in the
Union out of the 48 and make it 46, leaving only Wyoming and
Mexico. We ask your sympathy and later on in the convention
I want to ask for a resolution on this question which will help
us in our task.
With regard to the prospects of the Western Hospital Association, I am not a prophet, but I believe that this Association,
so young, only in its third or fourth year, has already demonstrated that it can carry out a broad educational programme,
such as the one we have before us today. Further, if we shall
continue to hold annual conferences, may be a question to discuss at our business meeting. We have these separate organizations, the B. C. Hospitals' Association, the Northwest Hospital Association, and in California we have not yet a State
Association, but we are working towards one. In the Southern
section of California we have a live organization under the title
of the Hospital Council of Southern California which is now in
its seventh year, having a membership of some forty institutions and holding monthly meetings. The respective sectional
organizations naturally should continue to hold annual, or even
more frequent meetings, but whether the Coastwise Conferences
can profitably be held each year is a thing we. need to perhaps
consider. Distances are great out here, I have travelled some 1500
miles by motor to come up here but I know I shall be well repaid, and we here from the far South will be glad to welcome
you down there. We look forward to a profitable meeting because the programme promises that. We look forward to an
enjoyable visit and to the making of many acquaintances and
friendships which will result in inspiring us to a greater devotion, to the task in which we are all engaged. As the meeting
goes on we will become better acquainted and will have an
opportunity to discuss matters which will be of benefit to us
all. Let us make all of our discussions of a vital and most instructive nature. I again express my pleasure in being here and
must apologize for the fact that I have not come prepared to
perform the function of a president but being only a vice-president you will bear with me I know.
13 Moved by Mrs. Broom, seconded by Mrs. Clute, '' That smoking be permitted at the convention."   (Motion carried.)'
Miss Mabel F. Gray, R.N., Vancouver, Secretary of the B. C.
Hospitals' Association, read the following communications:
An invitation to inspect the Vancouver General Hospital
received from Dr. R. A. Seymour, Acting General Superintendent.
Letter from Dr. Wrinch of the Hazelton Hospital in which
he regrets his inability to be present.
Letter from Mr. Grimmett, Merritt, B. O, regretting inability to be present.
Informal message from Dr. F. C. Bell expressing the hope
he will be present at the convention on Friday.
It was moved and seconded, "That the above communications
be received."   (Motion carried.)
Mr. G. W. Olson, introduced the following visitors to the
convention:
Mrs. Armstrong, editor of the "Western Hospital Review,"
Los Angeles, California.
Mr. Matthew 0. Foley, managing editor of "Hospital Management," Chicago, Illinois.
Dr. Moots, formerly of Toledo, but now of Mentone.
The following telegram was read from Mr. John A. Mc-
Namara, editor of '' Modern Hospital.''
"Every good wish for success of meetings, wish I could be
with you."
Telegram from Mr. G. W. Curtis, Superintendent Santa
Barbara Cottage Hospital, Santa Barbara, Calif.:
"Regret that my attendance at meeting impossible, best
wishes for a successful convention."
Moved by Mr. R. C. McCulloch, Abbotsford, seconded by
Mr. J. N. Coady, Vancouver, "That a Resolution Committee of
five be appointed by the Chair."   (Motion carried.)
The following members were appointed: Mr. R. C. McCulloch, Abbotsford, B. C. (convener), Miss Grace Phelps, R.N.,
Portland, Oregon; Dr. Howard H. Johnson, San Francisco, Cal.;
Mr. W. B. Huges-Games, Kelowna, B. O; Sister Mildred, Victoria, B. C.
Upon motion the meeting adjourned, 12 noon.
14 LUNCHEON
12.15 to 1.30 p.m.
Speaker—W. B. Burnett, M.D., CM., F.A.C.S., Vancouver,
B.C.
TUESDAY AFTERNOON SESSION
August 19, 1930
CHAIMAN: Mr. G. W. Olson.
The Afternoon Session was called to order by the Presiding Officer, Mr. G. W. Olson, who immediately called upon H. E.
Young, B.A., M.D., CM., LD.D., L.M.C.O, Victoria, B. C, Provincial Health Officer, Province of British Columbia, to give an
address on
"FINANCING OF HOSPITALS IN BRITISH COLUMBIA —
GOVERNMENT AID, ETC"
DR. YOUNG: I was asked to come here by the B. C. Hospitals' Association and as my work connects me up with the hospital work of the Province, they suggested that I might probably,
for the benefit of our visitors, outline just what the conditions
are in British Columbia in regard to the hospitals; what aid is
given them, and what of the future.
The financial question in hospitals, as I know it for the
past twenty years, is one that makes those in public life dream
and wake up sometimes with a nightmare, and I have no
doubt Superintendents of hospitals go through the same experience. It is always a hand-to-mouth existence and we are
sailing on a sea of which there does not seem to be any shore,
and always in difficulties. Now, in order to carry out public
work, or to give effect to the intentions of the people through
parliamentary procedure by passing Acts, you must have behind
you the weight of public opinion, and in order to carry on what
is semi-voluntary work, government aid, while very essential and
very opportune at times, produces in the public mind a condition expressed as "Oh, well! let the government do it." Voluntary aid falls off and you will find in British Columbia or in
any other province, where there are similar conditions, that you
never see a notice in the paper of some person bequeathing money
to the institution; occasionally it happens and when it does
it is a red letter day. And we are getting more and more into
the state of mind that hospitals will have to be supported by
a co-operative move amongst the people as a whole. In the
last analysis, the money that goes to hospitals, either by way
15 of collections or gifts or by government aid comes from the
people, but unless the giving is properly organized, it is sporadic — it is not sufficient and it takes the time and energies
of the people to whom great praise must be given when they
devote their time and effort to collecting these amounts.
Hospitals originally were intended as hospices, homes for
those who needed them, the poor, the needy and the derelict.
They were received in the early days into the monasteries or into
the houses built for the purpose and the public conscience felt
relieved that the responsibility had been taken off its hands.
As we progressed, however, in the development of individuals
and in the growth of the population, it began to be recognized
more and more that the people should through their governments, face the responsibility of the hospitals. The consequence
was that there was then set up a demand on the government
for such aid. This has been granted in a limited degree, but
the appetite has increased and these demands are increasing until it becomes a very serious question with the government as
to how to meet them.
I will give you some of the figures of the contribution of
the government of British Columbia — for there are certain
things which must undoubtedly be met by governments. The
police power is in the hands of the government, the regulation
of a great many of our activities is in the hands of the government. The education of the children is in the hands of the government and the care of the individual should be in the hands
of the government, and we will soon be unable to meet our
liabilities from governmental sources unless we curtail the expenditure for other and very necessary developments. In a new
country like this — and we are a new country — we have not
yet developed our potential wealth, we have not yet turned
our potential wealth into dollars and cents, and it imposes a tremendous burden upon the public activities of this province to
make all we have productive. We have a national debt to pay
interest on, we have foodstuffs to buy, we have schools to maintain and we have to build roads and bridges and all of the
other things. We have only so much money to do it with and
that money has to be contributed by the people in the form of
taxes, and if the people would just recognize their right to dictate as to how that money shall be expended, then we would
get away from this constant bombardment of the government
asking for this and that for their little section or for some particular department. The government of the country is the people
of the country and the people are those who contribute the
money to carry on the government of the country, and those
16 who are in power are simply stewards burdened with, and I
say, advisedly, burdened with the duty of the distributing of
that money. With the increase of education, with the development of the country, people should recognize more and more
that they should participate in the allotment of the monies of
the country. The great advances that have been made in social
and labor conditions, and in the raising of wages are putting
us on a different plane than we were 50 years ago, and we are
demanding now as necessities what 50 years ago were luxuries.
One of the demands we are going to make is that facilities
shall be furnished for the proper care of the jpopulation, because
people are recognizing more and more that the individual is
not the essential in the population other than in his relation to
the community as a whole, and we have to think in terms of the
community and not of the individual. The day we used to say
that "an Englishman's home is his castle" is gone. Today we
have to say to that man you are one of the components of the
community and your outgoings and incomings shall be regulated insofar as they may interfere with the benefit of the community as a whole, and in order to carry that out we pass certain regulations and rules and laws. We say that while we
have great potential assets in this province, we have to develop
them and the way to develop them is by the efforts of the
greatest asset of all, and that is the human asset. We must
approach each individual as the integral part of a community
and his outgoings and incomings are matters of very serious
concern to us all, because if he cannot support himself and produce something above his support which will create the national
wealth, then he becomes a liability, and the rest of us have not
only to carry on our work but we have to support this man and
look after him if he is sick, together with his family and his
dependents, and the result is that we are spending millions of
dollars in bricks and mortar building hospitals and homes for
the indigent, industrial homes and a dozen other things that
are constantly being forced upon the government. It is becoming a very serious question as to where we are going to get the
money. The government may have a deputation in one day demanding large sums of money for additions to hospitals or the
building of new hospitals. Probably a week or two weeks later
there will be another deputation, demanding that the taxes be
reduced. You cannot do both and you cannot get it into the
minds of the people that their particular section of the province does not represent the province, and that if they want
$100,000 or $500,000 spent in that section, it has to come from
the general pocket.    And when you say reduce our taxes, the
17 government can say we will but where will we get the money
for what you were asking for last week.
In British Columbia the financing of the hospitals has been
carried on in a paternalistic way, though not designedly so, but
the underlying policy of our financing has been that no citizen
of British Columbia shall be allowed to suffer as long as we have
hospitals, and the basis of an individual grant to these hospitals
has been founded on this—that as far as your accommodation
permits you must not refuse any one who comes to your doors.
Those who can pay, well and good. Those who cannot pay shall
receive exactly the same treatment and care as the others do,
and for this we will grant you certain monies. When this began
each hospital was dealt with individually, and they were given
to understand that they could send in their bills for their indigent patients. They did so. When the bills were made out
there was one idea in the people's minds who made them out
and that was to the benefit of the hospital and they did not
overlook anything on the bill, and the bills continued to grow
and grew out of all proportion to the services that were being
received until it became such a burden to the government that
they wiped it off and said "we will do this differently — we
will make a certain annual or daily grant per capita to every
hospital for every patient. We will give them a certain amount,
no matter whether the patient pays or not and that will give
them a sufficient surplus to take in those who cannot pay."
That payment was graded according to the number of days'
treatment and began with $1 per day for 1000 days' treatment
then 75 cents a day and so on until the larger hospitals in the
city were receiving probably 45 cents or 50 cents per day. The
question then came up that this was not enough to carry on
with, there were deficits. With that governmental action, there
was also a change in the public mind and the people got it into
their heads because the government was paying so much per day
for every person, that every person was primarily entitled to
free treatment, which was not the intention at all. A great
many people want something for nothing and a good many people
who were perfectly able to pay, would not pay. That necessitated an increase of the grants and then part of that responsibility devolved upon the municipalities. The municipalities were
forced by legislation to pay a certain amount for the patient
if he came from that municipality; but when he came from the
municipality that did not mean the hospital would lose the government grant. They got that contribution from the municipality in addition to the government grant, and then the same
old fight began again. It has been very hard to define a person
as indigent.   If a patient comes in from North Vancouver Muni-
18 cipality and it can be shown he is an indigent, that municipality
is notified and they are charged up with his account. But that
municipality may say he is not indigent, that the man owns a
house over there. No doubt he may own a house but it may
be plastered with a first, a second and third mortgage, and as
far as ready money is concerned, he is absolutely indigent. The
municipality has the right to try to recover from this man, but
so it went on, all'' passing the buck.''
Then there was another revision brought about, whereby
an amount of 70 cents per day was to be paid by the municipalities for every person. The municipalities would pay that
for their patients whether the patients paid or not. Then the
question of residence came in. How long must a man be in
the municipality before-he is considered a resident? It was suggested thirty days, but that has been altered and a man must
now be in the municipality three months before he is considered
a resident and before his bill is chargeable to the municipality.
A man may come in this week and announce his intention of
settling there and may buy a house. He is then immediately
considered a resident of that municipality, and his bill is chargeable to the municipality.
In 1923, we did not bring in an 18th amendment, but we
did alter our liquor laws, so that the government handled the
sale of liquor and derived a very substantial revenue which was
allocated in different ways. Part was given to the schools, part
to the hospitals and part to the roads, but that has since been
altered. Twenty-five cents a day in addition to what was being
paid to the hospitals, was alloted for each patient day and that
continued until last year when the liquor money, which had been
set aside and was kept in a separate liquor board account, was
simply all paid into the consolidated revenue, and an increase in
the government grant was made to compensate for this 25 cents
per day. So that possibly today in the smaller hospitals of say
1000 days' treatment, they may be receiving about $1.25 per
day for every patient. That decreases a little as the number
of beds in the hospital increases and the larger hospitals to-day
are getting I think, between 70 cents and 90 cents for each
patient. In regard to tuberculosis, a flat rate of $1 per day
was paid for each patient day, which is now under the new
arrangement, $1.25 per day.
We have a sanatorium but that sanatorium is crowded and
it was necessary to pay all hospitals who set aside at least 10
per cent, of their bed capacity to take care of advanced cases of
tuberculosis. This arrangement is not helping us very much. People will not come until the last minute when they are broken
19 down, and then they think they should immediately recover. They
are simply defeating the efforts of the sanatorium which is desirous of getting all of the incipient cases and treating them so that
they may be an asset to the community,—that they may be
able to make a living and also that they will be there as a nucleus
for teaching other people and their families how to live and how
to avoid tuberculosis, because tuberculosis is something we can
cure.
I want to give our visitors some idea, but I will not burden
you with a lot of figures, of what British Columbia has paid
to its hospitals during the past ten years. You must remember
that our population has been less than 600,000. We have paid
in the last ten years a total of $23,584,280. That is what the
government has paid, but that is not all it has cost the people
of British Columbia. In addition to what the government has
paid, the municipalities are paying also. The city of Vancouver
is paying as much as the government is paying. Then in addition to this, and you must remember this is for maintenance
of all institutions that look after the derelict, the broken-down
and the sick, we have paid, a per capita grant including the
liquor grant from 1923 and a special grant, to hospitals in the
past ten years of $7,835,000. I have included in that our sanatorium. The government took over the sanatorium in 1921 and
since then it has cost $2,118,000. The mental hospital has cost
us since 1920, $6,219,000. These are all for maintenance and
that brings it to a total of $18,765,000. Add to that the capital
grants of $4,819,000 for construction and you have a total of
$23,584,280 that the people through their government have spent
for this work.
That is pretty good. That is a remarkable record considering what we have spent in this country for other governmental
activities; considering we have to pay for our educational system. We have built a university of which we are very proud,
and the graduates from which are making remarkable records all
over the country and in other universities. And in regard to
education, looking at it from the economic side, we know that
if a man is sick, he is a burden and he is going to cost us money.
We know the best citizen is the educated citizen and we willingly spend that money too, but while we are doing all that
for brick and mortar and patching up broken-down characters
and producing wonderful results by operations, you are dealing
with the individual; you are not dealing with the community.
Each one of these is an individual who is sick. You cannot
eradicate the disease by curing it, you must prevent it, and it
is a matter of criticism, and justifiable criticism, of this gov-
20 ernment or any other government, and I speak advisedly, knowing I am a civil servant of the government, but I am speaking
in terms which apply to all other countries, that the money
spent in prevention is a bagatelle. Twenty-three million dollars
to cure disease and $140,000 a year to prevent disease. Every
government is wakening up to this fact that they cannot stand
the drain. It is running into billions of dollars on the North
American continent. They cannot stand this drain. Not only
this annual expenditure of money but there is the enormous
economic loss in the loss of production by the individuals who
are affected and who are sick, 40 per cent, of which loss may
be prevented.
The United States government is doing a wonderful work.
We are following along the same lines in Canada. In Great
Britain they began in 1915 when they found they wanted so
many men. If they had had all healthy men in the nation they
would have won the war that year. Lloyd George said he could
not make soldiers out of C-3 men. He said if their defects had
been remedied in childhood he could have put another million
men in the field that year. In the United States 43 per cent,
of the manhood of the United States, in their very best years
were rejected; 33 per cent, in Canada. Why? Physically unfit
to fight! If they were physically unfit to fight, they were
physically unfit to act as citizens and concern themselves with
the development of the country, • support themselves, help to
educate themselves and build up the country. And what are
we doing now in health work? This work throughout these
countries is remarkable. In the last 25 years the average length
of life has been extended eight years by care in prevention. We
are doing that in British Columbia. We were the first to introduce the examination of school children and we are doing a
wonderful work in correcting all defects that lay the foundation
for organic diseases in after-life. Every year we require $23,-
000,000 to cure disease, but prevention is the keynote. Health
work must be associated with the hospitals, and with the health
work the social side must be enlarged. The family history must
be enquired into, the extent of defects must be learned, and the
economic conditions improved to the extent that you will not
have the hospitals over-crowded with beds in the corridors. You
must have the realization that every citizen is an asset and that
the responsibility for looking after that asset is on you just as
much as the looking after of your own bank account. If you
do not look after that asset your bank account will be depleted.
CHAIRMAN: While I do not agree with Dr. Young in his
opinion that hospitals should be taken over entirely by the municipality or the state, that offers us a point for discussion.   Per-
21 haps there are other points you would like to discuss. His reference to the importance of prevention, that is one thing we in
the hospitals are taking more and more interest in, because we
do not want a return visit from our customers. I am sure all
those present are interested in prevention and this subject is
now open for discussion.   (No discussion.)
If there is nothing to say, I wish to thank Dr. Young because I shall conclude that silence is a full acceptance of Dr.
Young's remarks. With reference to his statement in regard
to prevention, that is a thing that is going to reduce the annual
demand upon the government's funds. The time will come when
more hospitals will ask for aid from the government, but this
much is certain that the government will never lose anything
by liberally supporting preventive work. We have found that
in the States and I am sure you have found that in this province
and in the Dominion. If there are no questions we will proceed
to the next subject.
The Chairman then called upon the next speaker, Malcolm
T. MacEachern, M.D., CM., D.Sc, Chicago, Associate Director
American College of Surgeons and Director of Hospital Activities, who presented the following paper on:
"THE RATIO OF HOSPITAL PERSONNEL TO PATIENTS"
DR. MacEACHERN: The ratio of hospital personnel to patients or beds is closely related to efficiency and economy, watchwords ever present and uppermost in the minds of boards of
trustees or governing bodies and hospital executives. A hospital
executive writes: "We are running behind rapidly in the operation of our institution. The deficit is steadily mounting. The
trustees are very much worried and are anxious to know if the
hospital is overstaffed in any of its departments. We must make
a drastic cut somewhere. Can you send us information as to
average ratio of personnel to patients in the various departments
and the general or total average?" This is the appeal frequently
heard.
To maintain a balance between efficiency and economy is
a big task which concerns other factors as well as the ratio of
personnel to patients or beds. It must be admitted, however,
personnel has a more important relation to efficiency than it has
to economy and should always be seriously considered, from the
former standpoint primarily. The proclaimed primary objective
of the hospital is the right care of the patient. This cannot be
assured by marble, bricks, mortar or glittering equipment alone;
it is the personnel which counts most — the number, type, and
quality responsible for the physical and scientific care of the
patient.   Any problem pertaining to the care of the patient must
22 therefore take into consideration the personnel involved and the
service rendered.   .
A survey of over one thousand hospitals on the Approved
List of the American College of Surgeons convinces the writer
that there is lacking adequate study of the problem of ratio
of personnel to patients or beds by the individual hospital. While
in this presentation the writer is attempting to submit definite
average® for various types of personnel based on what one thousand or more approved hospitals are doing, yet he believes the
proper solution to the problem is for each institution to study
its own work-load in relation to its personnel. This can be
done accurately and scientifically through the. recording of each
function or activity of any department or service with time
consumed1 over a period sufficient to establish a proper average
or cross-section. Such time-labor studies offer the most intelligent basis for establishing the ratio of personnel to patients or
beds in the individual hospital. A study of this nature can be
carried on to distinct advantage by any hospital.
Factors Influencing the Ratio of Personnel to Patients
In considering the ratio of hospital personnel to patients
several important factors must be taken into consideration, of
which the following are the more vital and worthy of attention :
Hospital Planning, Construction and Equipment:
The older hospital, as a rule, has a larger personnel for the
number of patients served than does the hospital built within
recent years. The modern hospitals — the ones now being built,
because of greater thought in planning, have the advantage in
the matter of reducing personnel and at the same time maintaining the highest efficiency.
One of the most important lessons hospital authorities are
learning is that the building constructed vertically rather than
horizontally or on the cottage plan makes for noticeable reduction in personnel. An instance of this is strikingly manifested
by the new Hudson City County Tuberculosis Sanatorium, at
Secaucus, New Jersey. The old sanatorium with its 195 beds
was described as "scattered all over the landscape." The new
building contains 500 beds, 400 under the main roof and 100
in the preventorium, yet the estimated increase in personnel for
the new institution is only twenty per cent. In line with this
change from the cottage or horizontal plan to the multiple storied hospital is a suggestion for the elimination of long and inaccessible wings which considerably increase the time and mileage consumed in catering to the patient's wants. The interior arrangement of the hospital is just as vital
a factor in influencing the ratio of personnel to patients. Small
wards, for instance, require a greater proportion of employees
than large ones, ho doubt one of the reasons for the higher ratio
of nursing personnel in private hospitals. Whether the rooms
are large or small, the utility rooms should be close to them so
as to effect a saving in personnel. Christopher G. Parnall, M.D.,
Medical Director, Rochester General Hospital, Rochester, New
York, recommends that the utility rooms open directly off the
ward units, whether of the public or semi-private type. Gladys
Sellew, Cook County Hospital School of Nursing, Chicago, in
her recent book on "Ward Administration," urges that rooms
for preparing stupes, poultices, etc., be close to the ward. She
also emphasizes the value of the central diet kitchen and the
central room for medical equipment as a means of saving time.
Some authorities contend, however, that the central system does
not result in reduction of personnel but merely relieves the
nurses of many duties not strictly educational.
The present-day tendency in hospital planning and construction is to save as many steps as possible in the performance of
the activities of the institution. To this end there is a movement to individualize, more or less, the facilities for each patient.
Extra plumbing, running water, and examining and treatment
facilities in close proximity to the patient aid materially in reducing the work load as well as operating costs.
The matter of upkeep both inside and outside the hospital
is another factor not to be overlooked in considering personnel.
For instance, an old hospital with wood rather than terrazo, tile
or linoleum flooring, needs more persons to keep it clean. Certain buildings will require more painting, repairs and general
up-keep than others; perhaps even a full-time maintenance group
for such work.
• The many types of hospital labor-saving equipment are too
well known to need enumerating. These work-savers are now
available for almost every department of the hospital, even to
mopping tanks which are said to enable three men to do the
work formerly done by five. Miss Sellew makes another suggestion along these lines, namely: "that hospitals agree on sizes of
dressings and sponges required in hospital work so that these
articles may be made by machinery and save the time of nurses
or other personnel." In fact the way is now paved for such a
procedure. by the Report on the Standardisation of Surgical
Dressings, published in June, 1930, by the American College of
Surgeons.    H the standard dressings recommended be adopted
24 by all hospitals it will be only a matter of time before these
dressings can be made by machinery instead of at the expense
of the time of nurses or other employees.
Types of Patients:
The variation in number of personnel is so great in hospitals
caring for special types, of patients that an average of all their
ratios can never be typical. The lowest ratio will probably be
found for ambulant, convalescent, and chronic patients. For
these the ratios are frequently 1 to 60 patients. Dr. John Bryant
of Boston, in his book on "Convalescence," states that the ratio
of personnel to convalescent patients should not fall below 1 to
30, though actual ratios are probably lower.
A marked difference is also found in personnel for chronic
and acute cases. E. H. Lewinski-Corwin 's report on the Hospital Situation m Greater New York shows that the hospitals
for tuberculosis and chronic ailments in 1922 averaged' a little
less than % employee per patient, while the average for general
hospitals was 1% employees per patient. The group of special
hospitals, including largely pediatric, maternity, and orthopedic
institutions showed a ratio of 1% employees per patient. T. B.
Kidner of the National Tuberculosis Association advises that
the non-professional personnel of a public tuberculosis sanatorium be 22 per cent, cf the bed capacity, which again is considerably less than we find in most general or special acute types
of hospitals.
It is quite apparent to all that acute cases require a higher
ratio of personnel than chronic or convalescent. Mental, pediatric, obstetric, and surgical wards all necessitate a higher ratio
of personnel and there is considerable variation among these
groups. Surgical services will require a larger ratio of personnel than will even acute medical cases. A time-labor study of
nursing care required for different types of patients at Mount
Sinai Hospital, New York City, brought out this fact most emphatically, one example cited being that of an adult case of mitral
stenosis requiring 3% hours of nursing service, whereas an eight
day gastro-enterostomy case required six hours. Many similar
examples of variation might be cited.
Type of Service:
No study of ratio of personnel to patients can be undertaken
without a careful analysis of the type of service rendered. If
the hospital is of the boarding house or hotel type giving little
more than room, board and nursing, as opposed to a genuine
scientific service, the number of personnel will, of course, be
25 low. From the standpoint of variety of service it is quite evident that the sanatorium may require a much lower ratio of
personnel than the acute type of hospital providing for many
kinds of clinical cases and thus requiring an all-round increase
in personnel. The more complete, thorough, and scientific service a hospital renders the higher will be the ratio of personnel
to patients. This is well illustrated in comparing two hospitals
in a city of 88,000. These two institutions were equally well
equipped and had the same staff of doctors and the same class
of patients. In one institution where the nursing personnel was
1 to 6 patients the post-operative surgical death rate was 5.5
per cent., whereas in the other hospital where there was 1 nurse
to every 1^ patients the post-operative death rate was only 1.8
per cent. This variation in results was attributed by the medical staff and management particularly to the difference in ratio
of nursing personnel to patients.
Type of Personnel:
It is quite evident that employees carefully selected with
due regard to their mental, physical, and character qualifications
will have some bearing on the number of personnel required.
One person well trained and efficient in a particular task is more
valuable than two partially trained for this work. The selection
of persons who are capable of thinking for themselves, with initiative and good judgment, characterized by industry and interest, will tend to increase the unit volume of work, as well as
bring about more permanency in the staff. The value of the
person with training and skill is illustrated in the work that
can be done by graduate nurses as compared with that of students. Albert W. Buck, Superintendent of the New Haven Hospital, found in a study of 84 hospitals that the number of graduate nurses was on an average one for about 14 beds, while the
number of student nurses was 2 to each 7 beds.
Further, there is the hospital that has a large amount of
work done by persons not on the payroll. Many sectarian or
church hospitals come in this category. Catholic sisters and
others give valuable and essential services without being on the
payroll or considered as fixed personnel of a given hospital.
Lewinski-Corwin's report, previously mentioned, shows that of
all the New York general hospitals a Catholic hospital had the
lowest ratio of personnel to patients, which he attributes to the
large amount of work done by the sisters. In some hospitals
volunteer workers carry a share of the work load which also
affects the ratio of personnel to patients. In certain hospitals
one type of employee will assume several different kinds of work
— the interne may replace the laboratory technician, the nurse
26 may replace the dietitian, floor nurses may do maid work, and
so on; whereas the very large hospitals usually have a staff
trained for individual tasks. Many hospitals, especially those
desiring to have accredited nursing schools, have delegated maids
or attendants to do the work not directly concerned with the
technique of nursing, in order to raise the educational standards
of the nursing curriculum.
Hours of Duty:
The number of hours on duty is closely tied up with the
number of personnel. For instance, one of the reasons more student nurses are required than graduate nurses is that the former
must devote a certain amount of time to lectures and study.
Some hospitals allow no time for study during hours on duty,
a factor in slightly reducing the personnel. Then again, the
nursing day varies from eight to twelve hours. The tendency,
however, is toward the eight hour day as the quality of the
nursing service is lowered beyond this point. Internes, too, will
serve fewer hours in hospitals where there are a great many
teaching clinics. Therefore, more are needed. Most hospital
personnel now are on an eight hour day schedule.
Seasonal and Geographical Variation in the Hospital Load:
That the seasonal rise and fall in the graph of average daily
patients is quite decided may be seen from figures presented in
the Philadelphia Hospital and Health Survey for 1929. The
Committee reports that "The maximum and minimum utilization
in both years (1927 and 1928) were identical as to month and
proportion of beds used: March, 70 per cent., and August, 57
per cent." A similar variation in patient averages may be expected in other northern cities having seasonal extremes. On
the other hand, hospitals of the southwest very likely show a
more or less constant number of patients from month to month
because the climate favors the sanatorium type of hospital and
the treatment of chronic diseases. Accordingly, the personnel
will remain more or less constant in number. The hospitals and
sanatoria located at summer and winter resorts will, of course,
show the greatest seasonal variation.
Policy of the Institution:
Whether a hospital is operated by a municipality or by a
private corporation has a distinct bearing on the number of
employees. The charity hospital is likely to show a still wider
ratio of personnel to patients than the private hospital. There
is also the institution having a large number of public wards
as contrasted with the one that gives individual service.   Like- wm
wise, the hospitals operated for profit and the non-prof it making
institutions are in two different groups. The religious hospital,
because of the voluntary aid it receives, will vary from the non-
sectarian. And finally, there is the teaching hospital which
needs additional employees to care for its students and to relieve the latter from work not truly educational.
Spirit of the Institution:
The spirit of the hospital is quite distinct from its managerial policy. Rather, it has to do with an indefinable attitude
of the executives and employees, an alertness, a willingness to
co-operate. Hospital morale is an important factor in the building up of a desirable personnel, characterized by such traits as
induce increased volume of work through inculcated qualities of
interest, industry, and co-operation. Much depends upon the
quality of supervision. The head of a department who takes a
professional view of his or her work is usually able to inject
greater efficiency into the work of subordinates. Moreover, one
who works out time schedules and specifies definite duties for
employees in his charge will doubtless be able to economize on
staff requirements.
Ratio of Personnel to Patients:
What are the actual ratios of personnel to patients in various
hospitals and groups of hospitals throughout the United States?
What are the ideal ratios recommended by authorities?
The 1929 census of the American Hospital Association shows
that 719,622 hospital beds are occupied each day. In ascertaining the number of employees an average ratio of nine persons
to ten beds was used. How does this hypothetical ratio compare with the actual?
The 1927 report of the Committee on County Hospitals of
the American Hospital Association shows that the general average ratio of total employees (including nurses) to beds was .52
or one employee to every two beds for 23 general hospitals. The
range was all the way from .09 to 1.07 employees per bed. The
average ratio for 32 county tuberculosis hospitals was .39 per
bed or one employee for every 3 beds, with a range of .11 to .76.
Lewinski-Corwin's average ratio of employees to beds for
28 general hospitals in New York for 1922 is decidedly higher
than any of these figures, being 1.17 per bed or one and two-
thirds employees per patient. The highest ratio was 2.20 per
bed or 2.48 per patient, while the lowest was .65 per bed and
.89 per patient. The average ratio of employees to beds for 23
special hospitals was lower than for the general hospitals, being
28 .96 or 1.21 per patient. Five hospitals for tuberculosis and chronic patients showed the lowest average of .41 per bed and .46
per patient, approximating that of the county hospitals previously mentioned.
Statistics of the United Hospital Fund of New York for 1926
show an average ratio of 1.30 employees per bed in 27 general
hospitals. The ratio of ten women's and children's hospitals was
.86 per bed, and for the 12 special hospitals was 1.15 per bed.
The six chronic and convalescent hospitals had an average ratio
of .59 per bed, slightly higher than that for the previous two
studies mentioned.
A survey of personnel in 105 hospitals, most of them general, published by Hospital Management showed a wide difference in personnel of hospitals having the same bed capacity.
For a group of 200-bed hospitals, in various large cities, there is
this variation in the number of employees: 100, 37, 114, 285, 180,
167, 60 and 170. As the average number of patients per day for
all 105 hospitals was 93 and the average number of employees
112, the general ratio per patient was 1.2 employees.
The staffing of individual hospitals is of interest, not only
from the standpoint of the ratio of personnel to patients in the
various units, but also from the classification and nomenclature
or designation of personnel. It is quite apparent from a review
of the distribution of personnel in several hospitals there is no
uniform method of distribution or standard nomenclature followed. This makes it much more difficult to work out accurate,
average ratios of personnel to patients in the various units. To
support this statement the following three examples are submitted: Hospital A, 275 beds, with an average of 200 patients
daily, maintains a personnel of 318, exclusive of physicians, distributed as follows:
Administration     8
Office   14
School of Nursing   37
Laboratories  -  14
Maintenance   21
Housekeeping  36
Steward's Department  36
Laundry _  17
Student Nurses   114
Not Classified   4
301
Hospital B, 440 beds, with a total personnel of 500. Through
a close check of its personnel for the past four years it is found
29 that during this time the average ratio of personnel to patients
has varied only from 1.73 to 1.76. The list of its payroll positions for a typical month is as follows:
Hospital Employees—
Administration  42
X-Ray    10
Laboratory   17
Occupational Therapy  _    2
Pharmacy  _     2
Cardiograph  1     2
Diabetic      1
Hydrotherapy       1
Out-maternity     1
Anaesthesia      1
Medical and Surgical     4
Ward Nurses      2
Dietary    83
Household  76
Laundry  32
Engineers, Firemen, etc  16
Elevator Operators  11
Carpenters       3
Painters      7
Orderlies   19
Nurses' Helpers   54
    386
School of Nursing Employees—
Nursing Staff  6
General Nursing   68
Household  _  18
Telephone   4
Dietary    „  16
Maintenance    2   114
Total number of employees   500
Hospital C, 195 beds, with an average of 150 patients daily,
maintains a total personnel of 202, making a ratio of 1 employee
to 1.34 patients, classified and distributed as follows:
General Administration     11
Nursing  _  106
Operating Room       6
Laboratory  _      4
X-Ray _....     4
30 *—
Dental  _  1
Drug  1
Records   2
Out-Patient  .,  3
Dietary  16
Housekeeping   24
Laundry  10
Mechanical   12
Transportation   2
202
It is desirable and would be of practical value to have a
further study made of the distribution and designation of hospital personnel in order that our institutions might have a better basis of comparison. This is undoubtedly an important factor bearing on the question under consideration, particularly
when ratios are developed for the different groups of personnel
associated with hospital work. The developing of such a classification would not be a very difficult task if the accepted principles of hospital organization were followed.
In studying the literature the writer finds that the opinion
of authorities on the ratio of total personnel to patients varies
all the way from less than one, to two employees per patient. It
is evident that no comprehensive study has been made of actual
ratios for large groups. In an attempt to learn more about the
prevailing ratios of hospital employees, with a view of establishing standard ratios in the future, so far as is possible, the writer
has just completed an analysis of 195 typical hospitals taken
from a group of over 1,000 hospitals approved by the American
College of Surgeons. These hospitals handle acute cases and are
representative of the average conditions existing in the larger
group. For the purpose of analysis the statistical reports were
divided as follows:
Group 1.—25 hospitals with 25- 49 bed capacity.
Group 2.—50 hospitals with 50- 99 bed capacity.
Group 3.—50 hospitals with 100-249 bed capacity.
Group 4.—50 hospitals with 250-499 bed capacity.
Group 5.—20 hospitals with 500 or more beds.
The findings of this survey show that the general average
ratio of total personnel (including nurses) is .69 or, approximately two-thirds of an employee per bed. The highest ratio
for any hospital in the group was 1V_ employees per bed while
the lowest was .13 for a eounty hospital having a large proportion of tuberculosis cases and employing only graduate nurses.
31
!•— By using seventy-five per cent, of the bed capacity to obtain
the average number of patients the ratio of personnel to patients
was found to be .90, or nine employees for every ten patients.
The range was from .18 to 2. per patient.
It is interesting to note that out of the entire list of 195
hospitals only 24 have a ratio as high as one or more than one
employee per bed. This is in marked contrast to the findings
of L'ewinski^Corwin which showed 29 out of 56 New York hospitals having one or more employees per bed. However, it must
be borne in mind when comparing ratios that many hospital
executives do not have the same ideas as to the meaning of '' total
employees," consequently there will be variations in compilations
of ratios. "Total employees" should mean "total payroll employees."
For Group 1 (hospitals under 50 beds) the ratio of total
employees was found to be .66 per bed and .87 per patient. The
lowest figure was .32 per bed, and the highest was 1^4 per bed.
For Group 2 (hospitals of 50 to 100 beds) the average ratio
of total employees to beds is virtually the same as for the previous group, the general average being .65. The ratio per patient
is .85. The two hospitals sharing the high r,atio of 1.26 employees per bed, or 1.72 per patient, handle a relatively large number of surgical cases and employ a greater proportion of student
nurses than graduates. The low ratio in this group is the low
for the entire list, which is .13, when graduate nurses entirely
were employed.
For Group 3 (hospitals of 100 to 250 beds) the average ratio
is .77, or H of an employee per bed, which is 1.06 per patient
— the largest general average for any of the five groups. The
range is from .31 to 1.32 employees per bed, or .41 and 1.76 per
patient. The highest ratio is, no doubt, accounted for by the
large number of surgical cases handled, which is 1,945 as compared with 652 medical cases.
For Group 4 (hospitals of 250 to 500 beds) the ratio of employees per bed again drops to nearly the same as for Groups
1 and 2, namely, .65. The extreme ratios are .21 and 1.29 employees per bed, which is .28 and 1.73 per patient.
For Group 5 (hospitals of 500 beds and over) there was an
average ratio of .75, three-quarters of an employee per bed, or
one employee for every patient. The high is high for the entire
group, while the low is .45 per bed or .61 per patient, found in
a city hospital.
Conclusion:
The general average ratio of nine employees for every ten
patients found in the survey of 195 hospitals is lower than for
32 any group quoted from the literature, save that for a study of
county hospitals. This figure approximates the estimated ratio
used by the American Hospital Association in determining the
number of hospital employees for its annual survey. The general average approaches that of a group of 105 hospitals in
scattered localities previously mentioned, but was considerably
lower than the figures given for two studies of personnel ratios
in New York City hospitals. It was found that the hospitals
in Groups 1, 2 and 4 had nearly the same general ratio of two-
thirds of an employee per bed or three-fourths per patient, and
that those in Groups 3 and 5 had corresponding ratios of three-
quarters of an employee per bed or one per patient. A great
range was apparent in the individual ratios.
Ratio of Nurses to Patients:
The Committee of the National League of Nursing Education makes this recommendation of nurse ratios in its 1920 report:
Free Ward Service—
Day duty   1 nurse to   5 patients.
Night  duty  % 1 nurse to 10 patients.
Private Ward Service—
Day duty   1 nurse to 3 patients.
Night duty   1 nurse to 5 patients.
S. G. Davidson, Superintendent of Butterworth • Hospital,
Grand Rapids, Michigan, advises the same ratio for day duty
but fo.r night duty suggests 1 nurse for 7 private room patients
and 1 for 14 ward patients, which would make a total of 33
nurses on duty in a hundred bed hospital. He also advises 6
for operating room; 2 for out-patient work; 2 for dietary; 2 for
affiliated courses, contagious and mental; 2 for pharmacy, X-Ray,
etc.; a total of 47 nurses in active service. In "Nursing and
Nursing Education in the United States" for 1923, five patients
is suggested as the maximum number that one student nurse
can satisfactorily tend. The ratio advised for night duty is 1
to 10 patients. Frank E. Chapman, Director of Mount Sinai
Hospital, Cleveland, takes up the matter of the number of nursing supervisors required. In his opinion a nurse in direct charge
of a nursing unit cannot efficiently supervise many in excess
of ten persons. A nurse supervisor could, the writer feels, take
60 to 75 patients but a head nurse not more than 25 to 30 patients
if the work is to be done properly. This has been established
from the surveys of approved hospitals. Nursing personnel of
a typical ward of 22 patients, as worked out by The Modern
Hospital, consists of one head nurse, one senior nurse, four in-
33 termediates, and two night nurses. This makes a ratio of one
nurse to four patients for day duty and one nurse to twelve
patients at night.
The average ratio of nurses to beds in 56 hospitals replying
to the questionnaires of the County Hospital Committee, previously mentioned, was .15 and the range was from .02 to .54.
The committee's report states that, making allowances for the
lack of detailed information, "a nurse bed ratio of less than .20
in general hospitals .... indicates a lower standard of nursing
service than is usually regarded as desirable in any general hospital, whatever local conditions may be." Ten, or forty-two
per cent, of the twenty-four general hospitals fall in this group.
And, it proceeds, "It may well be doubted also that a nurse bed
ratio of less than .10 ... . represents adequate nursing service
even in a tuberculosis hospital.... yet sixteen, or fifty-seven per
cent, of tuberculosis hospitals are no better equipped." However,
twenty-eight of the fifty-six hospitals state that they employ only
graduate nurses. In some cases this may account for the low
ratios.
As previously mentioned, Buck found the average number
of graduate nurses per bed to be .07. He also found that thirty-
eight of the eighty-four hospitals studied had an average ratio
for graduate nurses, between .04 and .07, so that the general
average is fairly typical in this instance. The average for student nurses he found was .20 per bed and the model class was
.35 to .39.
The Community Hospital of Riverside, California, has made
time studies of its nursing personnel, which are described by
Dr. C Van. Swalenburg. The average number of patients for
the two months of the study was 24.5. At the end of twenty-
four hours the supervisor of the nursing unit totalled all the
hours that any nurse had served on the unit, including her own
time and that of the superintendent of nurses. The average
nursing hours per day per^patient were found at the end of the
time study to be 2.78. The average nursing hours, which were
70.9 per day at eight hours, means 8.86 nurses per day of twenty-
four hours. Consequently 8.86 nurses for 24.5 patients gives a
total of 2.76 patients per nurse.
In addition to the general ratios the writer has made an
analysis of nurse ratios to patients, based On the figures of 1,196
approved hospitals out of the total of 1,266 included in the 1928
list of accredited nursing schools of the American Nurses Association. As individual figures on daily average patients were
given these were used in computing ratios. The average ratio
of nurses to patients for all of the 1,196 hospitals was found to be .62, approximately two-thirds of a nurse per patient.   The
ratios varied from 1.53 nurses per patient to .02.   This last, exceptionally low, was for a municipal home and hospital.   Of the
entire list of hospitals only 83 show a ratio of one or more than-
one nurse for every patient.
The average ratio of nurses in the hospitals of 25-49 bed
capacity was .80 per patient. Individual ratios ranged from
1.30 to .10, the latter in a hospital employing only graduate
nurses. In hospitals of 50-99 beds the ratio was three-fourths
of a nurse per patient, with a range of 1.52 to .07. The low figure again is in a hospital employing only graduate nurses. Out
of the 1,196 hospitals analyzed 592 fall in the classification of
100 to 249 beds, and for this large group the average ratio of
nurses to patients was .65. The high is 1.53, referred to above,
and the low figure, .06, is shared by three hospitals, all of which
employ only graduate nurses. For hospitals with a bed capacity of 250-499 the average ratio is .54 or one nurse to every
two patients, with individual variations from 1.07 to .10 per
patient. The forty hospitals with 500 beds and over have an
average of .39 per patient, the high and low ratios being 1.01
and .02.
As the employment of graduate nurses seemed to have a
direct influence upon the ratios, an average ratio of nurses to
patients in those institutions using solely graduates was obtained
and found to be .17, considerably below the general average for
hospitals employing a combination of graduates and students.
Just as surprising was the discovery that only twenty-two hospitals of the entire list of 1,196 employ graduates to the exclusion of student nurses. The range for these twenty-two having
graduates was .06 to .50. Excluding this last high figure the
range is from .06 to .38, approximating the range of .02 to .31
obtained by Buck.
Conclusion:
The analysis of 1,196 hospitals shows that the proportion of
nurses required for each patient decreases as the size of the hospital increases. The average ratio of hospitals under 50 beds,
for example, is .80; in hospitals of 50-99 beds it is .74; in hospitals of 100-249 beds it is .65; in hospitals of 250-499 beds it
is .54; while the ratio in hospitals of over 500 beds drops to
.39. This analysis also substantiates the general opinion that a
pronounced reduction in nursing personnel is made possible by
the employment of graduate nurses solely.
Ratio of Internes to Patients:
While the interne is not considered as a payroll employee in
35 the hospital, the ratio to patients merits consideration. The
eighty-four hospitals surveyed by Buck were found to have an
average ratio of .02 or one interne per fifty beds. The range was
from one per one hundred beds to one for fourteen beds.
The total capacity of the 613 hospitals approved by the Council on Medical Education and Hospitals of the American Medical
Association for interne training, according to figures of November 30, 1929, is 182,895, and these hospitals have available 5,262
interneships. On this basis the ratio would be .03 per bed, but
it is probably lower in view of the existing shortage of internes.
Another factor is the employment of resident physicians in place
of internes.
In its Essentials in a Hospital Approved for Internes the
Council on Medical Education and Hospitals states that the ratio
of patients to internes should be 25 to 1 at least. Using the 195
statistical reports previously mentioned, as a basis, the following
data on internes has been secured. Only two of the 25 hospitals
in Group 1 employ internes. As these two hospitals listed but
one interne each the general proportion was only one to 370
patients. In the 50 hospitals in Group 2, hospitals 50-99 beds,
there were a total of 30 internes. Thirty-nine of these hospitals
reported no internes at all, two had as many as six. The ratio
is one to every 86 patients. In Group 3, hospitals of 100-249
beds, there were 138 internes reported, making a general ratio
of .01 per bed or one interne for every 50 patients. Thirty-tiiree
of these hospitals had at least one interne and 21 of them had
between three and five internes. One hospital had an interne staff
of 12, a ratio of .06 per bed. A total of 393 internes was listed
for Group 4, hospitals of 250-499 beds, a ratio of .02 per bed
or one to 33 patients. Thirty-seven of these hospitals had five
or more internes. The highest ratio was .09 per bed. Only two
hospitals reported having no internes — one of these had three
resident physicians in place of internes.    The average ratio for
19 of the 20 hospitals in Group 5 is .03 per bed or one interne
for every 25 patients. (One hospital was omitted from the computation as the number of internes was included in the resident
staff).    All except one hospital employed internes and 12 had
20 or more. The highest ratio was .08 per bed. Three of these
hospitals reported eight resident physicians each, and one had
nine residents in addition to internes.
Conclusion:
From this study it would seem that the number of internes
per bed increases proportionately with the size of the hospital.
The hospitals with less than 100 beds employ a negligible ratio
36 of internes per patient and usually have a resident. It is generally agreed, however, that the average hospital should have
one interne to 28 patients. In an "open" hospital this is frequently much lower, that is, one to 35 or 40 as a maximum.
Ratio of Dietitians and Food Service Employees to Patients:
In answer to the question "How many food service  employees should this 250-bed hospital have?" Hospital Management for July,  1926, published   data   from sixteen hospitals,
giving their own figures and estimates as follows:
Lake View Hospital, Danville, Ulinois.... 125 beds 13 employees
(Estimate) ~  250    " 26        "
Iowa Methodist, Des Moines, Iowa  193 patients 14       "
Norton Memorial, Louisville, Kentucky.... 110 beds 14        "
St. Barnabas, Minneapolis, Minnesota  175   <l 19       "
(Estimate)  250    " 7    kitchen only
Missouri Baptist, St. Louis, Missouri  360    " 56 employees
Wilkes-Barre General, Wilkes-Barre, Pa... 250    | 12        |
Milwaukee, Milwaukee, Wis.  (Estimate) 250    " 22-24   "
Taeoma General, Taeoma, Washington  120 patients 18 part cafeteria
(Estimate)  250 beds Q? emplovees
Jersey City, Jersey. City, New Jersey  250    % 22 plus pupils
Thomas D. Dee Memorial, Ogden, Utah.... 107    " 10 kitchen only
(Estimate)  250    " 18      " |
Woman's Hospital, New York  530 patients 15 employees
Robert Packer, Sayre, Pennsylvania  235 beds 11 kitchen only
(Estimate)  250    | 11-14" " "
City Hospital, Worcester, Mass  400    " 48 employees
Jackson Memorial, Miami, Florida  300    " 24       "
(Estimate)  250    | 22-24   "
Presbyterian, Philadelphia  536 people 34       "
Methodist, Los Angeles  950 meals 29       "
(Estimate)  250 beds 34        " '
In some of these hospitals student nurses are employed for
dietary work and in others nurses take no part. Some of the figures include service to employees also. Such factors account for
variations.
Maude Perry, formerly dietitian of the Montreal General
Hospital, in a study of 66 hospital kitchens, reported that hospitals having between 1,000 and 2,000 beds had a range of from
one to eight dietitians; those between 500 and 1,000 beds had from
one to nine dietitians; those from 250 to 500 beds had from one to
fifteen dietitians; those from 100 to 250 beds had from one to
three dietitians; while hospitals of less than 100 beds had one
dietitian. She points out that hospitals of 250 to 500 beds are
seemingly better staffed in this department than either larger or
smaller institutions.
Katherine Mitchell Thoma, dietitian at Michael Reese Hos-
37 pital, Chicago, indicates that a fair average is one dietitian for
50 to 75 patients.
The author's study of the ratio of dietitians, based on the
195 approved hospitals, showed the following:
25 hospitals in Group I   had an average ratio of .009 per patient
CA t t tt ' < TT    <'       i < ' * "       ll     01        " "
tn it tt tt        ttt    tt      it it n      tt    01       " "
50      "        "      "      TV "    "        " "    I .008  "       "
oo      " "      "        V  "    "        " "    "   009   "       "
35 hospitals in Group II had at least 1 dietitian.
An n n i t ttt    tilt        tt       -i tt
and 9 had 2 or more dietitians.
^k      tt        tt      it      jy  a   tt     it    j      tt
and 26 had 2 or more dietitians.
All in Group V had at least 1 dietitian, and 19 had 2 or more.
Conclusion:
Taking this group as a whole the general ratio is about one
dietitian per 111 patients. Each of the given groups approximate
this ratio though Groups II and III would seem to be somewhat
better staffed, having an average of one per 100 patients.
Ratio of Social Workers to Patients:
This study of the 195 approved hospitals showed that no
hospital under 50 beds employed social workers and that only
two of those with 50-99 beds had social workers. Seventeen hospitals, however, in the next group of 50 had at least one trained
social worker, and one reported as many as five. The average
ratio is .004 per patient or one to every 250 patients. Twenty-
three of the hospitals with 250-499 beds have at least one social
worker and four have as many as eight each; one reported 11
social workers. The average ratio here is .006 per patient or
one to about every 175 patients. Of the 20 hospitals in the last
group 17 have one or more social workers, and one reported 22.
The general average is .008 or one to every 125 patients.
Conclusion:
From this data it would seem that few hospitals under 100
beds employ social workers, while those over 100 beds show a
corresponding increase in ratio of social workers as the bed
capacity increases. The writer's conclusion is that there should
be one social worker for every 150 to 20OJ patients in a mixed
hospital caring for free, part-pay and pay patients.
Ratio of Adjunct Nursing Personnel to Patients:
Adjunct nursing personnel usually includes orderlies, nurse
maids, and male and female attendants.    These are sometimes
38 known as ward attendants or aides. Buck estimates the ratio
for attendants, based on his study of 84 hospitals, to be .02 per
bed or one for every 50 beds. S. S. Goldwater, M.D., of New
York City, in his recommendations for ward planning advises
one orderly to a male ward and says that a hospital caring for
the acutely sick requires the assignment of at least two responsible persons to a ward.
Referring again to the study of 195 approved hospitals the
ratio of adjunct nursing personnel is found to be as follows:
Hospitals of   25-49   beds   1 to every 33 patients
"    50-99    I "     "      25     |
"  100-249   " |     I      25     I
| 250-499  " "     I      25     "
" 500 beds and over 1 to every 25 patients
Conclusion:
From investigations in these 1,000 or more hospitals it is
found that, generally speaking, there is need for one orderly or
male attendant to every 35 patients, or one for every 25-30 patients by day* and 40-50 by night. In general, every hospital
could utilize one female or ward attendant for each 15-20 patients. This has a definite bearing on the number of nursing
personnel.
X-Ray Department:
The degree of time which the radiologist devotes to the hospital, as well as the character and amount of work passing
through the department, has an important bearing on the number
of persons required to adequately staff the X-ray department.
Hospitals doing a large amount of major and time-consuming
X-ray work such as gastric and intestinal series, gall bladder
visualization and pyelography will require more personnel than
the hospital carrying on the routine work of which the major
portion is of skeletal nature. Further, the addition of work from
the out-patient department and from doctors in private practice
outside of the institution will have a material effect on the number of personnel required. All these factors must be borne in
mind when making a study of this problem.
A very careful and extensive study of the personnel required
for X-ray departments in various sized hospitals has been made
by E. S. Blaine, M.D., Chicago, Director of the Department of
X-ray, National Pathological Laboratories. He has offered some
valuable suggestions pertaining to this subject which may be
followed as a sound basis in working out the personnel for hospital X-ray departments, with which the writer is heartily in
39 accord. He states there is a noticeable trend towards the selection of a part-time chief roentgenologist of high calibre in both
large and small" hospitals, in place of a full-time man of less experience. The appointment of a part-time roentgenologist will
probably mean the employment of one or more additional persons
less highly experienced to do routine work in the department.
This is desirable, however, for a competent roentgenologist is too
valuable to be compelled to take over the duties of a technician.
The following-is a summary of Dr. Blaine's recommendations for
staffing the X-ray department of the average general hospital,
in which there are both medical and surgical cases:
Less than 50 beds—1 part-time chief roentgenologist
1 part-time technician
50-75 beds—1 part-time roentgenologist
1 part-time technician
1 part-time stenographer
75-100 beds—1 part-time roentgenologist
1 half-time technician
1 part-time stenographer.    •
100-125 beds—1 part-time roentgenologist,
1 full-time technician.
1 half-time stenographer.
125-150 beds—1 quarter-time roentgenologist.
1 full-time technician.
1 half-time stenographer.
150-175 beds—1 quarter-time roentgenologist.
2 full-time technicians.
1 half-time interne.
1 full-time stenographer.
175-200 beds—1 half-time roentgenologist.
2 full-time technicians.
1 full-time-interne.
1 full-time-stenographer.
200-250 beds—1 half or full-time roentgenologist.
2 full-time technicians.
1 full-time -interne.
1 full-time nurse.
1 full-time stenographer.
250-300 beds—1 half or full-time roentgenologist.
1 full-time assistant roentgenologist.
2 full-time technicians.
1 full-time interne.
40 1 full-time nurse.
1 full-time stenographer.
300-400 beds—1 half or full-time chief roentgenologist
1 full-time assistant roentgenologist.
1 full-time student roentgenologist.
3 full-time technicians.
1 full-time interne.
1 full-time nurse.
1 full-time stenographer.
400-500 beds-
500-750 beds—1
2
1
4
1
1
9
half or full-time chief roentgenologist,
full-time assistant roentgenologists,
full-time student roentgenologist,
full-time technicians,
full-time interne,
full-time nurse,
full-time stenographers.
full-time chief roentgenologist.
assistant roentgenologists.
student roentgenologist.
technicians.
interne.
nurse.
full-time
full-time
full-time
full-time
full-time
full-time stenographers.
750-1000 beds—1 full-time chief roentgenologist.
2 full-time assistant roentgenologists.
1 full-time student roentgenologist.
5 full-time technicians.
1 full-time nurse.
2 part-time internes.
2 full-time stenographers.
-1 full-time chief roentgenologist.
3 full-time assistant roentgenologists.
2 part-time student roentgenologists.
6 full-time technicians.
2 full-time nurses.
3 full-time internes.
3 full-time stenographers.
It will be noted that in the above suggestions, Dr. Blaine
has made provision for the training of internes and student roentgenologists, who, of course, will carry their share of the technical work so that they may be justly considered as personnel.
Clinical Laboratory:
The factors mentioned when considering the personnel of
the X-Ray Department apply equally well to the clinical labor-
1,000 beds and over-
41 50-100 beds-
100-200 beds-
atory and need not be repeated. An exhaustive study of personnel required to adequately staff the clinical laboratory in
the various sized general hospitals has been made by J. J. Moore,
M.D., Chicago, Director, National Pathological Laboratories, and
pathologist to a number of leading hospitals. At the request of
the writer he has submitted the following carefully worked out
schedule for staffing the clinical laboratory of the average general hospital:
Less than 50 beds—Visiting pathologist who would call for a
short time once a week or once every
two weeks, the pathological material to
be sent to him daily for examination.
1 technician, capable of assisting in other
departments when her time is not fully
occupied in the clinical laboratory.
-Visiting pathologist who would call for a
short time daily, or at least three times
a week.
1 full-time technician.
1 part-time interne.
-1 part-time pathologist.
2 full-time technicians.
1 full-time interne.
1 part-time stenographer.
200-300 beds—-1 half-time pathologist.
3 full-time technicians.
2 full-time internes.
1 half-time stenographer.
300-500 beds—1 full-time pathologist.
1 full-time assistant pathologist.
5 or 6 full-time technicians.
3 full-time internes.
1 full-time stenographer.
-1 full-time director as head of laboratories.
1 full-time assistant director as head of
pathological department.
1 full-time assistant director as head of
the serological and bacteriological departments.
2 to 4 full-time technicians in each department.
4 full-time internes.
2 full-time stenographers.
500-1000 beds-
42 1,000 beds and over—1 full-time director as head of laboratories.
1 full-time assistant director as head of
pathological department.
1 full-time assistant director as head of
the serological department.
1 full-time assistant director as head of
the bacteriological department.
An adequate number of technicians in
each department.
4 to 5 or more full-time internes.
3 or more full-time stenographers, as required.
Inasmuch as hospitals over 100 beds have internes, Dr. Moore
feels they could be considered as laboratory personnel and do
the following work:
Surgical Service—Examination of tissues, both macroseopi-
cally and microscopically, for operations at which he
assists, under direction of the pathologist.
Medical Service—Perform all laboratory service on their
patients other than preliminary laboratory work performed by the technician and that done in combination,
such as blood chemistry, etc.
Laboratory work should be assigned to the interne, not with
the idea of making him a super-technician but rather to familiarize him with the fundamentals and the interpretation.
The number of technicians required depends on the extent
to which the laboratory is used. The above suggestions are for
the average hospital where the physicians on the staff use the
laboratory to the required extent. This pre-supposes that the
necessary work for approved hospitals is a routine procedure.
As the volume of work increases more technicians as necessary
must be employed, but the increase in supervision is not relatively as rapid.
Physical Therapy Department:
Careful study of a large physical therapy department by the
writer over a period of years convinces him that one attendant
or aide, with the usual variety of treatments and with up-to-
date facilities, cannot adequately care for more than fifteen or
sixteen patients per day. This statement is borne out by figures
submitted through John S. Coulter, M.D., Chicago, Assistant Professor of Physical Therapy, Northwestern University, and member of the Council on Physical Therapy of the American Medical
43 Association, who has had extensive experience in observing the
needs of hospital physical therapy departments and studying
all aspects of the problem. "One physical therapist, attendant
or aide to take care of sixteen patients as a maximum," is the
recommendation of Dr. Coulter. He explains that this is on
the basis of an eight-hour day in general hospitals, with an alternating schedule of heat, massage, and exercises. He further adds
that the hospital having a large number of orthopedic cases
will probably find the ratio more adequate if there is one physical therapist, attendant or aide to every ten patients.
"The trend seems to be toward a part-time medical director
for the physical therapy department," Dr. Coulter states, "in
order to secure the best skill available. For the hospital in the
smaller town it is perhaps more desirable, however, to create
a full-time position by having the radiologist in charge of the
X-ray, physical therapy, and occupational therapy departments;
otherwise the part-time physical therapist may be competing
against those in private practice and thus fail to secure the full
co-operation of the medical profession which is so essential."
Here, also, the type of case must be taken into consideration, as well as the volume of work from in and out-patient
departments of the hospital. Further, there is a considerable
difference in the character of treatments, some consuming much
more time and energy than others. All these factors have an
important bearing on the, ratio of personnel to patients.
Telephone Operators:
It is stated that the regular telephone operator working
eight hours a day in a hotel carries 100 to 150 local calls an hour
with ten trunk lines. This ratio will obtain to practically the
same extent in hospitals, providing the operator is not obliged
to handle patients' information. Possibly an operator for every
150 to 200 patients in the average hospital might be adequate.
From a survey and study of hospitals it would seem that one
operator for this number of patients appears to be the general
ratio.
Maids:
On enquiry the writer finds that the largest hotel in Chicago
has for its housekeeping department a definite ratio of one
chambermaid for every seventeen rooms. In addition, one bath-
maid takes care of the seventeen rooms and one houseman who
does the vacuum cleaning takes care of twenty-five rooms. For
this three thousand-room hotel 210 day maids are employed, 42
night maids, and 25 housemen.   As the majority of good hotels
44 have a ratio of one employee for every room, which is comparable
to the ratio per patient in many hospitals, the above figures
may also serve as a guide for the housekeeping department of
the hospital.
Engineering, Maintenance and Repairs:
For the hospital of less than 50 beds one janitor should be
able to handle all work having to do with upkeep of the buildings, maintaining the heating plant and doing minor repairs.
The hospital of 50-100 beds will require one or two helpers for
routine work, in addition to a janitor. If an engineer is employed to replace a janitor the former can be expected to undertake most of the minor repairs and simple construction. The
hospital of 100-250 beds will have a considerable increase in its
engineering and maintenance staff. For this group the recommendations made by Edgar Charles Hayhow, formerly of the
Department of Management, New York University, may be taken
as a guide. He advises that the personnel be as follows: One
engineer to supervise plumbing, electrical and construction repairs; one assistant helper; crew of two or three helpers to
cover twenty-four hour service; one handy-man to assist in daily
routine; one or more full-time painters. The hospital which
approaches 250 beds in size will probably also need an additional handy-man, an extra helper or two, and possibly a carpenter. A supervising chief engineer and two licensed assistants are required for the hospital of 250 beds and over, according to Mr. Hayhow. In addition, two plumbers, one plumber's
helper, one electrician, one refrigeration man, and several carpenters, handy-men, and painters are required. The number of
personnel, particularly in the larger hospitals, will vary with the
arrangement and age of the buildings and type of mechanical
equipment. A saving in personnel in this department does not
always mean economy to the hospital, for frequent and regular
repairs are necessary in order to prevent deterioration of building and equipment. In fact, Mr. Hayhow goes so far as to say
that thorough overhauling and replacement of worn-out units,
together with readjustment of mechanical activities, frequently
not only justifies the initial expense but also cuts engineering
maintenance costs in half.
Conclusions:
A survey of a cross-section of hospitals on the Approved
List of the American College of Surgeons revealed a personnel
ratio of nine employees to every ten patients. While few comprehensive surveys have been made of the ratio of personnel to
patients, the consensus among hospital authorities is that there
45 •should be at least one employee for every patient. On this
basis the figures obtained by the writer fall short of the desired
mark, but it should be borne in mind that the hospitals were
chosen, not with the idea of substantiating an opinion, but rather
to reveal conditions in the various types of institutions. From
personal observations of service to patients in hospitals throughout the United States and Canada, the writer feels that the general hospital handling acute cases should have one or more than
one employee per patient. Hospitals which have made names
for themselves through offering the very highest type of care
to the sick usually have a ratio of at least five employees to
every four patients, and generally three employees to every two
patients. However, when the ratio becomes two employees to
every patient, cost to the patient is materially increased, hence
such a policy has its drawbacks.
The study of these 195 hospitals revealed a range of .18 to 2.
employees per patient. This wide variation demonstrates that
an average obtained from a study cannot be taken as a standard
for all hospitals in determining the proper ratio of personnel
to patients. The difference of minimum and maximum ratios
simply indicates that, because so many factors influence the number of employees needed, each hospital is a law unto itself so
far as the staffing of it is concerned. How, then, shall the number of employees needed in proportion to the number of patients
be determined, some hospital executives may ask. The answer is,
carry out a work-load study. Put each department and each
division of each department under scrutiny to determine the minimum number of persons required to complete a given task adequately over a definite period of time. Such a work-load study
cannot be completed in a month or even several months; it
should be a continuous process, in that records of the number
of patients and the number of persons employed in each department should be kept up-to-date. Then when the time-study
figures of the number of employees needed for a brief period
are compared with the actual number employed over a long period of time, one can strike an average ratio of personnel to
patients that will be accurate enough for all practical purposes.
Permit the writer to stress again the need for every hospital to
determine its personnel requirements by undertaking a workload study at the earliest possible opportunity. It is one of the
principal solutions of the way to strike a balance between efficiency and economy.
CHAIRMAN: We thank you most heartily for this presentation.   I have a feeling that if all our speakers cover their sub-
46 jects as thoroughly as Dr. Young and Dr. McEachern, there
will be no need for any discussion.
(No Discussion)
CHAIRMAN: I shall now call on Howard H. Johnson, M.D.,
F.A.C.S., Director, St. Luke's Hospital, San Francisco, California,
who will speak to us on the subject of:
"THE HOSPITAL, T\HE DOCTOR AND THE PATIENT:
THE FUNCTION AND RESPONSIBILITY OF THE
HOSPITAL IN THIS TRIUMVIRATE"
DR. JOHNSON: The title selected for this paper is rather
long and imposing, especially when we consider that the answer
is short and simple. The title also has a sting in its tail—"triumvirate." Whether or not this word was used by design or chance
in framing the subject to which I was to write, it actually does
apply to the situation in some hospitals in a manner which most
of us are very likely to construe it, when we think of Roman and
French history. It may apply to other hospitals in the same manner that the term has been applied to a group of three men who
strove independently along similar lines in the personal accomplishment of what ultimately became an epochal piece of work,
as did Cezane, Van Gough and Gauguin, called "The Glorious
Triumvirate in the Development of Post Impressionistic European
Art." Neither one of these uses of the word should apply to our
triumvirate.
There is another kind of triumvirate or governing group
which I shall try to describe later, totally different from the
foregoing.   But first let us see why we should avoid the first two.
The year 59 saw the Roman Republic powerless in the hands
of three citizens, a triumvirate. They were three rivals, who
for the time being, buried their own personal ambitions and
jealousies in order that they together might exploit the resources
of Rome and divide its honors and its wealth by robbing the citizenry, and at the first opportunity kill off one or both rivals,
in their greedy quest for personal gain. As is usual in such
triumvirates, two of the three combined to accomplish banishment for the third, and soon the inevitable battle for supremacy
between the remaining two ended at Actium, in defeat of the
profligate, and with an end of the anarchy which follows in the
wake of. jealous, personal striving for selfish gain.
The other type of triumvirate exemplified by Cezane, Van
Gough and Gauguin should not be patterned after, inasmuch as
47 each, by chance or design, worked independently along a comparatively uncharted course,, with perhaps the usual amount of
plagiarism, envy or jealousy.
The third triumvirate, if such there is to be in our world,
should have none of the qualities of either of those we have just
discussed. There is no question, of course, regarding the fact
that there are three principal factors to be considered in our
work — the patient, the doctor and the hospital — and there
is no denying the fact that these three factors are sometimes
arrayed as triumvirates of either of the two classes mentioned.
It is needless to say, of course, that our own triumvirates are
well balanced and functioning along lines that good triumvirates
should function, but it may be just as well to mention the fact
that they may become unbalanced, so that we may be on our
guard and so that the barbarian may be warned.
It is decidedly questionable whether we should use the term
triumvirate at all from the standpoint of clear expression and
good understanding. The term Benevolent Dictatorship might
well be substituted, with the Patient's best interests as Dictator,
and the Doctor and Hospital as executive advisors.
Let us assume, then, as a basis for discussion at least, that
our triumvirate shall be conducted along the lines of a Benevolent Dictatorship. What, then, shall be the principles governing
its operation and what shall be our duties, obligations and privileges in this dictatorship?
The first article of our charter will be — The Patient First.
The last article and all the other articles between the first and
the last, shall be the same — The Patient First. All the great
charters or documents having to do with human action are based
upon very simple principles, and we always find that the more
nearly we keep these principles in mind, and the less attention
we pay to the development of laws, regulations, restrictions and
rules that someone thinks necesary for his own or someone else's
benefit or control, the better it is for the general run of those
supposed to be governed or privileged under the charter. A
notable example of what happens to a very simple principle, and
a great document is before us daily — the Constitution of the
United States, the two million laws presumably based upon and
carrying out the Constitution, and the most notorious of all these
laws, the one prescribing prohibition.
I have never yet been confronted with a problem or difficult situation that required executive decision, which could not
be decided easily, promptly, accurately, and judicially,, with
this one rule in mind — The Patient First.    I   am   absolutely
48 certain that no question will ever arise regarding the function
and responsibility of the hospital in its relation to the other
two of our group which cannot be answered promptly, easily,
and judicially with this principle as the one and only guide.
The doctor, or Prime Minister, of our Benevolent Dictatorship, has given years of his life to the study of what is best for
the patient. The patient has selected his doctor with confidence
in his ability to look out for his best interests, his health and
often his life or future welfare. This relationship of doctor to
patient is extremely personal. The responsibility of the doctor
for and to his patient cannot be divided. The relationship and
responsibility of the hospital to the patient and the doctor, then,
is perfectly plain, in fact, first, none but well trained, honest
doctors shall be permitted to practice in our hospitals; and,
second, that the hospital shall care for the patient as the doctor
directs.
With these principles agreed upon, it now remains for us
to determine some of the more important details in the carrying out of our principle, The Patient First, in our service to
the doctor, who is the direct representative of our patient.
The modern hospital is one of the most complex of our present-day organizations. The highest type of executive skill is
required in the proper organization and operation of the modern hospital. The necessity for the highest type of executive
control is recognized by leading corporations and business organizations of the world. Someone has said: "Show me an organization and I will describe the man at the head of it." These
points are being recalled to your mind with the idea of emphasizing the point, namely, that a competent, capable executive in
the technical fields of his work, possessed with the principle,
The Patient First, and influenced in everything he does by it,
will handle the countless hundreds of details which come to him
for action without difficulty or fear of criticism or reproach.
In other words, the application of this principle to the most
complex of hospital problems, granting, of course, technical
training and skill in the mechanics of hospital operation, will
lead to proper solution of any hospital difficulty or responsibility
without the necessity for minute instructions or attention to
complicated conventions prescribed for the handling of this and
that or the other situation which may arise in the complex day
of the average hospital man or woman.
I should say. then, that the most important duty of the hospital administrator would be the selection and training of hospital personnel along the lines required, for them to practice and
live this one principle of our charter—The Patient First.   The
49 heads of special departments, and the workers therein,- will frequently develop a worm's-eye view of the principle. They will,
because of the requirements of their particular tasks, require
perspective. The executive head of the organization should be
constantly on his guard to see that the heads of the departments
and the individual members of the hospital staff shall maintain
the proper perspective and the proper balance between the duty
to the patient and the job. Very often, the accountant will feel
that some procedure in billing or collecting data or information
for his credit department is absolutely essential, but when the
scheme is viewed by an even-handed, humane executive, it will
be found irritating, embarrassing or uncomfortable to the patient. Under the circumstances, the accountant will have to be
encouraged to find some other means of solving his difficulties
other than one that would embarrass the patient, and lend force
to the argument that many hospitals are being conducted for the
benefit of the personnel, rather than for the accommodation of
the patient, and that hospitals are becoming so institutionalized
that the patient is lost in the whirl of business detail which seems
to be of more importance than comfort, sympathy and peace for
the patient.
The technical skill ofi the hospital executive and of the department heads and of the individual worker in the hospital will
amount to nothing if all their efforts are not controlled by that of
the patient's interests a%nd by consideration of what will happen
to the patient in the carrying out of any proposed hospital project. When we consider the simplicity of the rule and the simplicity of its application, there should be no difficulty in handling
any one of the modern hospital functions in its proper place and
with maximum efficiency in this Dictatorship.
There are many methods or means of promulgating the principle—The Patient First: at the weekly conferences; by the
routine holding to the principle, which speaks louder than words
or talk; by cards placed about the institution so that the principle may be kept constantly in mind; by example in the performance of duty; by constantly reminding those who have got
into difficulty of the fact that they have in some way violated
the principle, "The Patient First"; by reading to employees
and training school classes special bulletins on the subject at
stated intervals; and by numerous ways which will occur to the
individual familiar with the particular circumstances or job to
be handled. It is a a fact, however, that this principle can be instilled into the minds and hearts of all of the hospital workers,
from top to bottom, that it has been done and has been found to
50 be the simplest method that has been heard of in obtaining what
we might call one hundred per cent, hospital service.
Some of our personnel require an abdominal section or severe
attack of pneumonia, or some other illness to convince them of
the fact that the hospital exists for the patient, but even these
illnesses and operations come to our assistance at times. Not
long ago, a very expert steam-fitter complained of a pain in his
abdomen. He was promptly taken in charge by the house staff,
acute appendicitis diagnosed, operation recommended, accepted,
and performed. After two weeks of convalescence and two weeks
of sick leave, the steam-fitter returned to the hospital and to
see me. He spoke of his splendid care, of the apparent personal
interest in his welfare, and ended by saying: "And, doctor, I
know what this hospital game is all about now. I didn't know
what it meant when I was asked to repair a sink or a pipe, to
get more steam to Surgery, or to do any one of the things I was
asked to do; it seemed just an ordinary steam-fitter's job to me,
but since I have gone through the mill myself, I know what it
means to keep things in order for the patient."
CHAIRMAN: Is there any discussion on this very interesting
paper ?
(No Discussion)
CHAIRMAN: I shall now call upon G. Harvey Angew, M.D.,
of Toronto, Ontario, Secretary Hospital Department, Canadian
Medical Association, to present as his subject:
THE RELATIONSHIP OF THE MEDICAL PROFESSION
TO THE HOSPITAL
DR. AGNEW: Before I speak on the subject which has been
assigned to me, I would like to draw your attention to the fact
that at the last session in Ottawa, the government, as many of you
know, passed a number of revisions to the tariff regulations which
will permit a large selection of hospital equipment not made in
Canada to come in duty free. You will recall at the last meeting
in Nanaimo, you very kindly passed a resolution requesting such
Government action, and armed with your resolution and with
those from other hospital associations, we were able to approach
the Government during last year and we were able to get some
considerable concessions which I am sure will mean a saving of
hundreds of dollars annually to the hospitals of Canada.
Within a very few weeks, as soon as we get some definite
data from Ottawa, we will send to every hospital a pamphlet
51 reviewing these recent tariff revisions, and I am mentioning this
point at this particular time because since the change of Government last month there has been an announcement that the iron
and steel schedule will be completely revised again and this hospital tariff revision comes under the iron and steel schedule and
there is just a possibility that if the revisions are revoked this
concession to the hospitals may go by the boards. Although I
am sure it is not the intention of the present Government to
make any change in that revision, I would request those who
know Members of Parliament here and who have Members on
their Board to make it a point to draw this matter to their attention and request them to watch any legislation at Ottawa,
no matter upon which side of the House they sit, and we trust
that we can hold all that we have already gained.
The subject upon which I have been asked to speak is one
which is of such continued interest to us all, no matter what our
relationship to the hospital world, that it never grows old. The
many phases which may be discussed seem boundless and are
as varied as the colours of your glorious mountains at the sunset
hour. I am particularly interested in this subject because my
work with the Department of Hospital Service of the Canadian
Medical Association has given me an unusual opportunity to
study hospitals throughout Canada and to gain a binocular vision
of the relationship of the medical profession and the hospitals.
The stereoscopic vision resulting from, on the one hand, the fact
that most of my time and thought is devoted to administrators
and trustees and their problems, and, on the other hand, my
close association with the Canadian Medical Association, has been
of tremendous assistance in the effort to properly evaluate hospital problems and see them in their true perspective.
Trend Towards Hospitalization:
The hospital of today has a changed significance to the
medical practitioner. It was not so very long ago when the
alliance between the doctors and the hospitals was far from
close — when the average doctor did not care very much whether
or not he was on a hospital staff at all. But the increasing complexity of diagnosis, our increasing dependence upon the laboratory, the increasing technical development of medical and surgical treatment have rendered hospital care almost essential for
the full utilization of present day knowledge and methods. Home
conditions are changing, gone is the big spare bedroom and the
spacious verandah. With and without his assistance, the doctor's activities are being transferred more and more every year
to the hospital.
52 Hospital Privileges:
This increasing dependence of the doctor upon the hospital
has brought to the fore the question of "hospital privileges." In
smaller centres where every doctor in good standing is on the
hospital staff, the problem settles itself, but in larger centres
the situation is not so easily settled. It is generally agreed that
the "closed" hospital permits much better co-ordination of services and in many cases more efficient treatment, but it is not
fair today to close the private wards, at least, in a community
to practitioners of good reputation. The problem is to provide
that degree of freedom or "openness" which will permit a
licensed doctor to give his patient the best of modern care, without permitting the unscrupulous, the careless, or the over-ambitious doctor to attempt treatment not in the best interests of his
patient and at the same time jeopardize the reputation of the
hospital. Certainly the hospital, through its organized medical
staff, of course, should never fail to protect its patients against
inferior medical care and it should be the duty of the staff to
accept this responsibility on behalf of the hospital.
The most successful hospitals are those whose medical staffs
appreciate their appointments — who take their responsibilities
seriously, whose scientific enthusiasm is of a high order and
who are exceedingly, jealous of the scientific reputation of their
hospitals, for it is an axiom beyond dispute that no hospital can
rise above its medical staff.
Increasing the Efficiency of Medical Staff:
The question then as it confronts you, who are in the main
administrators and trustees, is "How can we assist our medical staff to achieve still greater efficiency?"
The standardization movement of the American College of
Surgeons has been a most powerful factor, possibly the outstanding influence in stimulating better staff organization. Also,
the approval of hospitals for interneship by the American Medical Association has been salutary to our larger hospitals. But
what can you do locally?
The holding of staff meetings should be encouraged. It is
a wise policy indeed to go to some trouble and even expense to
facilitate these meetings. Rooms should be provided, and some
hospitals go fifty-fifty with the staff in the purchase of lanterns
and other equipment — or purchase it outright for them. The
staff luncheon has proven one of the best means of getting out
the recalcitrant and the backslider and it is much better to provide facilities in the hospital, even at some inconvenience, than
to require the staff to dine elsewhere away from their clinical
53 equipment and cases. One good lady superintendent, who is
directing in a somewhat haphazard manner the course of a rather
water-logged and badly listing institution, positively refused to
let the medical staff have luncheons because she had a strong
objection to the odor of tobacco in the hospital. She should
have been here this morning when we were taking that vote to
permit smoking.
Staff appointment and promotion should be by merit. I
do not imply for a moment that long years of faithful service
should not be recognized, but the responsibility of the hospital
to its patients requires that unless seniority is backed up by a
record of achievement, of service and of scientific zeal, not to
mention a number of other vital qualifications, the honor should
go to someone more likely to prove a leader to his service.
Moreover, hospital authorities are becoming convinced that
almost all staff appointments should be on an "annual basis." It
is much easier to drop an unsatisfactory man by omitting to
re-appoint him that it is to dismiss him. However, chiefs of
services should be on a three-year basis, at least. A keen leader
with far vision may not vindicate his reorganization of a service
for several years and might suffer wrongfully if the ploughed
ground were not permitted to bear fruit.
The Interne Problem:
With the increasing number of hospitals and the reduced
output of medical graduates, it is becoming increasingly difficult for any but the best hospitals to obtain their quota of
internes, for today the interne can select a hospital where he
knows that he will be compensated for his labors by sound clinical instruction from an interested and scientific staff. Dr. H.
H. Murphy of Kamloops, one of your B. C Hospital Association
directors and one of the keenest minds in the Council of the
Canadian Medical Association, speaking on this subject in Montreal a year ago said:
"I do not believe that our profession in general have yet
fully awakened to their responsibilities in this matter. Their
responsibilities! Nay, their opportunites! For no man can
teach wthout learning himself; no man can discuss a case with
his own interne without clarifying his own thought; and no hospital can embark on a course of tuition, be it for nurses or physicians, without very definitely improving the character of the
work done in that institution, for here as elsewhere, 'More blest
is he who gives than who receives, for he that gives doth always
something get.' "
54 The Administrative and Professional Viewpoints:
One of the biggest handicaps in many hospitals today is the
frequent lack of full co-ordination between the administrative
and the professional groups. That there will be differences of
opinion can but be expected, for each group, highly specialized,
is approaching the common task from a viewpoint which, while
not diametrically opposed to the other, is certainly qualified by
different factors.
The doctor has one main objective — the treatment of his.
patient. His duty is to save that life if humanly possible; he
may request equipment beyond the hospital's ability to purchase, but if there are instruments that can make diagnosis or
surgery more efficient, it is but natural to desire them; he may
waste long ends of catgut, but when his patient's life and his
professional reputation are staked on one last desperate operation and every second counts if the Grim Reaper be foiled, the
harassed mind of the operator has no time for non-essentials.
H doctors call during meal hours it is not so often due to
thoughtlessness as to the fact that the harried doctor, never his
own boss, knows not what the next hour may bring forth and
must work in his hospital visits whenever his impatient patients
will permit.
The administrator or the trustee on the other hand, must
balance the budget; you are from Missouri when it comes to
laying out several hundred dollars for some piece of equipment,
especially when you recall that that two hundred dollar "what-
do-you-call-it" that you bought last year has not been very extensively used.
Our great difficulty is that we don't understand each other.
The doctors ask for something and fail to say why; the Board
of Management turns the request down — and also fails to say
why. The happiest hospital families, the most smoothly running institutions are almost invariably those wherein the medical staff, the trustees and the superintendent get together at
regular intervals and just talk things over.
I wish every hospital represented at this convention could
arrange say, every three months, to have a joint luncheon, of
the trustees and the medical staff. I have had the pleasure of
attending such luncheons and of hearing informal chats on the
need for this or that and the results have been far beyond expectations.
The Study of Non-Medical Hospital Problems:
I wonder how many of you who are administrators realize
that, next to the patient himself, the doctor is your greatest
55 publicity agent. The doctor's recommendation to the patient
or the family and his loyal support at all times are factors of
paramount importance in maintaining the average census. And
conversely, every time a doctor remarks that a certain hospital
charges too much, or is mercenary, or "too efficient," or the
patient can be treated as well at home — he is dealing a body
blow to that institution.
In my frequent contact with medical men I sometimes hear
the hospital criticized for its parsimony and frugality in providing clinical equipment or service and its lavish expenditures
on other features apparently non-essential. There is little doubt
but that some of these comments are sometimes true, but so
many times they are erroneous and the statement has been made
without a true appreciation of the facts — of the administrative problems besetting the superintendent and the Board.
It would be one of the most fruitful steps ever taken, if
each and every hospital represented here today could arrange
this fall to have one of your trustees or the administrator, armed
with facts, address the medical staff on the "Administrative
Problems of Our Hospital." Few doctors have had pointed out
to them the actual cost of setting up the operating room, the
loss on indigents, the actual cost of the laboratory and X-ray
work on the public wards, the cost of a training school, the fact
that a good hospital has more paid employees than patients,
the loss occasioned by the use of proprietaries in the pharmacy,
the difficulty of obtaining conscientious and skilled help — to
mention but a few problems known to you all. Few doctors
have visited the boiler room, the kitchens or the laundry. A
financial statement especially compiled for and with a view to
interesting the medical staff would be well worth the cost. Your
medical staff would appreciate this movement. As Dr. Murphy
says, "No hospital staff that concerns itself with hospital costs,
be it maintenance or construction, but will find its advice eagerly
sought and carefully weighed."
Medical Men as Trustees:
It is not my intention to make more than a very brief reference to the question of a medical voice on the board of management. One gathers that the consensus of opinion as expressed
in hospital journals, at hospital conventions and elsewhere is
opposed to medical representation. Certainly some doctors have
been thorns in the flesh to their fellow-trustees and without
doubt some have used their position for personal gain.
But I wonder if opinion is as unanimous as seems on journal pages or at hospital conventions.   After all the voice of the
56 practising physician is seldom heard in either place, I am sorry
to say. The difficulty seems to be that in so many instances
the doctors on the board do not represent anybody but themselves, or an estate, or a municipal council. If a doctor be
appointed by the medical staff to represent medical needs, if
he be carefully chosen, if he represent the medical staff as a
whole, not a faction in it, or himself, and if he be the only spokesman of the medical profession and if no doctors be elected to
the Board excepting those representing the staff — then, I am
thoroughly convinced, the hospital would gain, rather than lose,
by such an arrangement, for the technical experience of the
physician should be of tremendous assistance on many occasions.
An alternative arrangement is the creation of a medical advisory committee of three or five. This should be appointed by
the medical staff — not by the board of trustees — and should
have advisory but no executive powers.
The Hospital's Duty to the Doctor:
I have spoken of the doctor's duty to his hospital which
has decreased his mileage and his labors, has minimized his
worries and saved his time, and given his patients an increased
chance for recovery. But sometimes the desire to increase efficiency and to institute special free clinics of every description
may be overdone at the expense of the doctor. He is expected
to give cheerfully up to one third or one half of his time to
free clinics; he is expected to write voluminous notes, to fill out
insurance papers or lodge papers on charity patients, come down
at night, lecture to the nurses, teach the internes, and accept
a host of other duties. -Occasionally he may pick up five dollars
but he rarely gets even a letter of thanks at the end of the year.
Yet he can be sued, and has been sued many times, by ungrateful indigents or their relatives. Therefore, if the physician or
surgeon is to be asked to assume, in increasing doses each year, a
great load of responsibility, it is but fair that he be given for
this work the best possible clinical facilities by the hospital which
he serves.
This is a somewhat sketchy consideration of a well-nigh inexhaustible subject, but the outstanding thought which I wish
to leave with you is this: that every decade we are going to
see the interests of the hospital and the medical profession thrown
closer together, that each is quite dependent upon the other,
that each has a definite responsibility to the other, that the medical profession as a whole is taking a much more active and intelligent interest in the general problems of its workshop than
ever before, and that the benefits to be derived by all of us
57 seeking a closer co-ordination of our work should stimulate us
to still greater effort to achieve this co-operation.
Chairman: I believe we shall have to forego any discussion
on this subject, as the time is getting late. Our next speaker
is Mr. Matthew 0. Foley of Chicago, Editorial Director, Hospital Management.    Mr. Foley will speak on:
"HOSPITAL PUBLICITY AND COMMUNITY RELATIONS:
A BETTER UNDERSTANDING"
MR. FOLEY: The orthodox beginning for a talk on hospital
publicity and community relations is to say that a satisfied patient is the best publicity. It may be, however, that a patient who
has received good service, through unfamiliarity with hospital
methods, cannot appreciate this service, and may even be dis-
. gruntled. So, "a satisfied patient is the best publicity" presupposes that the patient is satisfied because of some knowledge of
what constitutes good hospital service.
It is interesting to find three of the largest fund-raising
organizations in the United States agreeing that "good service"
is the first essential of a successful hospital campaign. There
are other essentials such as well-known sponsors, organization,
active workers and so on, but when representatives of three large
fund-raising organizations recently were asked to tell what they
considered the most important single factor in, a successful campaign for funds, each replied independently of the others that
the first essential was.good service. One of the replies stated
that good service, or as it was termed "a good cause," was much
preferable to a poor cause even if the latter were supplemented
by a large group of widely known sponsors, an active organization, splendid publicity and so on, while the "good cause"
lacked some of these factors.
When one considers the subject of hospital publicity a little
more fully one sees that there are two kinds of publicity, direct
or voluntary, and indirect or involuntary. Under the heading
of indirect publicity comes all contacts with patients, visitors
and the public, such as those made by the telepone operator,
information clerk, etc., as well as by nurses and other personnel
who deal directly with patients, visitors and the public.
A short time ago newspapers carried a dispatch, the gist
of which was that a stranger came to a hospital one day and
asked to see the superintendent. The hospital employee who
met him asked the nature of the man's business with the superintendent.   The reply was that it was a personal matter.   When
58 the hospital representative answered that a more definite reason
had to be given before the superintendent could be disturbed, the
newspaper dispatch says, the stranger drew a cheek for $50,000
from his pocket, tore it into bits and walked out of the institution. One moral from this incident might be that everyone who
has even the slightest contact with patients, visitors or the public should regard every visitor as the potential possessor of
a $50,000 check.
When one thinks of hospital publicity one usually considers
what might be called direct or voluntary publicity such as activities of ladies' auxiliaries or aids, bulletins, annual reports,
National Hospital Day programmes, activities of the school of
nursing, fund-raising campaigns, newspaper write-ups and so on.
Publicity obtained by the hospital from sources such as these is
more or less planned, as contrasted with the publicity that develops from contacts of personnel in their ordinary daily routine.
For some time past it has been noticed that direct or voluntary
publicity efforts of hospitals have materially increased in recent
years. How much attention the hospital field pays to publicity
of a more direct nature may be imagined from a summary of
a questionnaire recently sent ^to 540 hospitals, most of them of
a community type. On the basis of the replies received to this
questionnaire, the publicity activities listed are practiced by the
percentage of hospitals indicated:
Ladies' auxiliaries or aids, 78 per cent.;
Write-ups in daily newspapers, 77 per cent.;
Talks before churches, clubs, etc., by representatives of hospital, 74 per cent.;
National Hospital Day programmes, 71 per cent.;
Distribution of postal card views of the hospital, 63 per
cent.;
Patients' leaflets, 55 per cent.;
Printed annual reports, 54 per cent.;
Bulletins, 35 per cent.;
Moving pictures or stereoptieon lectures, 20 per cent.;
Paid publicity workers, part time or full time, 20 per cent.
Among publicity efforts involving nurses were public graduation exercises, 94 per cent.; distribution of nursing school prospectuses, 73 per cent.; appearance of nurses at church services,
66 per cent.
Forty-one percent of the hospitals reported the use of a
card in newspapers and 38 percent reported a hostess or similar
person.
59 This study not only shows a growing interest in publicity,
but a wide variety of methods. Some of the unusual methods
of attracting the attention of the public reported included—large
electric signs on the buildings, a daily column of news about patients in a newspaper, and a revolving beacon. The variety of
publicity material and methods suggest the need of a careful
study by organizations interested in hospitals and a more specific
outline of what constitutes ethical hospital publicity.
One of the reasons for the increasing interest in hospital
publicity is that rising costs of hospital service, due to improved
service,- expansion and increased volume, necessitate greater support from the public for hospitals. A great deal has been written
and said about hospital costs, but this subject recently was summed up very fully and conclusively by Dr. MacEachern when he
said in effect that hospital costs in the great majority of instances
can not be reduced or even maintained at their present level
without impairing the quality of service or reducing the quantity
of service, neither of which, of course, is to be considered.
Increasing cost of hospital service means that fewer wage-
earners will be able to pay for treatment, and this means that
the hospitals can logically expect greater demands for free and
part-pay service. In five eastern states in which studies of hospital finances were made it was found that community hospitals,
on an average, spent a dollar and a half on a patient for every
dollar that the patient paid. The difference between what the
patient paid and what the hospital had to spend to give the needed service had to be made up from endowments, public and private donations, taxes and from other sources. The need of a
hospital for help from sources other than patients' receipts is
one of the principal reasons why hospitals are giving more attention to means of developing greater community interest and
support.
That big returns are possible from an organized effort on
the part of any hospital to make the community understand its
needs is shown by the two following statements:
A recent nation-wide survey of philanthropic contributions
in the United States shows that only 74 donors in 1,000 who contributed to educational, religious, charitable, welfare and other
activities gave their money to a hospital. The other 926 contributed to some other agency. Hospitals conducted by churches,
advance religion; many hospitals conduct schools of nursing and
train other health workers, thus contributing in a practical way
to education; still other hospitals serve the poor and those unable to pay full cost of their care. In other words, there are many *
hospitals that combine under one roof educational, charitable and
60 religious activities, and yet this survey has shown that philanthropists support education, religion or charity separately to a
much greater extent than they support hospitals which combine
a number of these worthy objects.
The second indication of the possibilities of an education
effort on the part of hospitals is based on a study in an eastern
city of the United States some years ago which disclosed that of
4,000 wills admitted to probate, only 12 contained bequests to
hospitals.
Thus, on one hand, we have 926 philanthropically inclined
individuals passing hospitals by to support activities, which, in
part, are carried on by hospitals in addition to service to the
sick, and on the other hand we have an average of 997 wills in
1,000 in which the work of hospitals is ignored. Undoubtedly
among these philanthropists are many who would be only too
willing to assist hospitals if they knew more of the work that
hospitals are doing and this suggests the returns that are possible
from a continued effort on the part of many hospitals to make
the public understand their work.
In conclusion, executives and trustees of hospitals will be
interested to know that hospital boards and foundations are
beginning to expect a sympathetic attitude from persons seeking
positions as superintendents of hospitals. A number of positions
recently were reported to have been filled on the basis of the
interest of the individual selected in the public relations of hospitals, and there is one foundation whose hospital representative
has said that the time is past when hospital administrators can
centre all their interests inside the walls of the building. This
representative asserts that the superintendent of a hospital must
look outside as well as inside the hospital and that he or she
must consider the hospital as an important factor in community
affairs and constantly take advantage of opportunities to make
the public better acquainted with the work of the hospital.
CHAIRMAN: Do you wish to discuss this question or shall we
leave it over to the round table discussions?
(Discussion left over until later sessions)
CHAIRMAN: I wish to thank every one of the speakers who
have appeared before us and discharged their duty wonderfully
well. I would also thank the audience for the close attention
and keen interest you have taken in the subjects that have been
discussed here this afternoon.
Upon motion the meeting adjourned—5:15 P.M.
61 TUESDAY EVENING SESSION
August 19, 1930
At 6.30 p.m: the British Columbia Hospitals' Association entertained the visiting delegates at dinner at which Mr. J. H.
McVety, President, presided.
The following telegram from His Honour the Lieutenant-
Governor was read by the Chairman:
"Please accept and convey to the members of your convention, greeting and heart-felt wishes for the continued
success of your generous efforts on behalf of our hospitals.
There can be no finer service to the State."'
(Sgd.) R. Randolph Bruce, Lieutenant-Governor.
The after-dinner speaker was Sir James Barrett, K.B.E.,
C.B., C.M.G., M.D., F.R.C.S., Melbourne, Australia, who gave
a short address on the "Victorian Bush Nursing System,"
his address being illustrated by lantern slides. Sir James
Barrett stated that there are at present 44 nursing centres
and 25 hospital centres operating under the Victorian Bush
Nursing Scheme. Subscribers who pay an annual fee to these
hospital centres are not called upon to pay when they become
patients at these institutions. Others who do not subscribe must
pay full rates. It is an excellent scheme and has worked out
admirably in the more remote sections of Australia and in his
opinion he could see no reason why it should not work out as
satisfactorily in the large cities. Everyone must go to the hospital at some time or other, so why not pay in advance? These
hospitals had refused to accept aid from the government as they
do not wish to come under government control. Sir James Barrett concluded his address by stating that as long as the present
system of hospitalization is in vogue, hospitals will remain expensive places.
On behalf of the City of Vancouver, His Worship Mayor W.
H. Malkin presented to Dr. Malcolm MacEachern a magnificent
seven-piece silver tea service in recognition of the splendid work
he had done in connection with the recent Hospital Survey Commission. Dr. MacEachern thanked the mayor and the citizens
of Vancouver for the beautiful gift which he stated would always
have the best place in his heart and home.
62 WEDNESDAY MORNING SESSION
August 20, 1930
PRESIDING: Mr. G. W. Olson.
CHAIRMAN: Round Table Nursing Section, Miss Jean
Harrison.
The Morning Session was called to order by the presiding
officer, Mr. G. W. Olson. In the absence of Miss Emily L. Love-
ridge, R.N., superintendent of the Good Samaritan Hospital,
Portland, Oregon, Miss Jean Harrison, superintendent of the General Hospital, Prince Rupert, B. C. conducted the Round Table
arranged by the Nursing Section. Miss Harrison called upon
Miss Carolyn E. Davis, R.N., Everett, Washington, Superintendent Everett General Hospital and President Northwest Hospital
Association, who presented a paper on:
"THE CHANGING NURSING ERA"
MISS DAVIS: The past few years have focused more attention upon nurses and the nursing profession, than any decade
of years preceding it. Heretofore, but little attention was given
to nurses, or to their education except by the profession itself. Up
to this time a nurse was accepted because the supply did not
equal the demand, and regardless of the type or amount of her
basic or professional education, her services were constantly
sought.
The late war was the beginning of a changing era in the
nursing profession as well as with many other lines of work.
When large numbers from our dependable ranks were recruited
for camp and foreign service, schools of nursing were frequently
forced to fill their positions with less competent personnel and
to accept any one who offered herself as a student nurse. This
seemed the only way in which the nursing needs of the country
could be supplied. With the return of large numbers of nurses
from the service, and many of them to their former positions,
a new situation developed. Schools of nursing were already
manned with a student body, many of whom had entered from
a patriotic sense of duty and whose enthusiasm waned with their
patriotism, yet they soon became members of this growing body
of graduate nurses.
The "survival of the fittest" applied here as elsewhere and
the profession gradually found itself faced with an increasing
amount of unemployment among its members. After much deliberation between the leaders as to the cause of this unemployment
and consideration of plans for future development a study of
the profession itself was undertaken.   The group finally selected
63 to do this work have been known as the Grading Committee.
A five-year programme was outlined, and although the study is
only in its fourth year, the reports from this Committee have
attracted nation-wide interest to the nursing profession, from
all groups of people interested in any branch of a health movement as well as educators in general.
In order to keep pace with the advancement made in all
branches of education the past two or three decades and particularly with the medical profession whose scientific development eclipses the work of generations before it, nursing education has undergone a complete change. The young woman trained by repetition to do a piece of work well, is no longer acceptable. To-day nursing, if well done, has become a fine art and
requires the highest type of intelligence to interpret and carry
out the demands made upon it by the medical profession. In
order to meet these demands, special teaching is required and
nurse instructors whose only duty is teaching, became necessary.
The scraps of a hospital's spare time could no longer meet the
rapidly expanding curriculum. Education in its truest sense,
and not merely training young women how to do a few treatments, has become the order of the day in schools of nursing,
as evidenced by the tie-up between them and several of our
universities and colleges. .
Glen Frank said recently when addressing the Nurses' Convention in Milwaukee "By virtue of its strategic position, in the
field of medical practice, it takes its place among the accredited
professions of modern society."
Hospital administrators recognize that the hospitals' richest
possession is its school of nursing, yet they are severely taxed to
meet the growing educational requirements and to provide an
efficient nursing service at low cost. The size of the school must
be increased or supplemental graduate service must be supplied
to meet the growing class room demands. Either method affects
the monthly balance sheet. No longer is the nurse in training
regarded as cheap labor for a hospital.
People are patronizing their hospitals more and more each
year and just as a community is learning to judge a hospital
by the "yard stick of standardization qualifications," so will
it soon judge its school of nursing. The reports of the Grading
Committe have this year laid before our trustees a living picture of their school. Unquestionably many surprises were revealed where comparisons were made. Trustees, particularly,
when composed of an educated group of men or women are going
to study problems of their school of nursing to determine,
64 1. Its real value as a school;
2. Its value to the hospital;
3. To find out what it costs to maintain their school;
4. To interest themselves in knowing whether their graduates are prepared to meet nursing obligations in the
varying communities into which they go, or whether
they become a part of this great unemployed group.
Upon the answer to these four problems. will depend the. future
of many schools of nursing.
Now let us consider the nurse in the field. Twenty years
ago, except for the few institutional positions, private duty
claimed nearly all graduate nurses. Her services were rarely
called for except in the so-termed well-to-do family, and there
was very little "special nursing" in hospitals. Possibly this was
because there were not enough nurses to care for the outside demand. With the passing years, people have more and more come
to appreciate the service and comfort real nursing care can bring
to both the sick and the family until today there is a general
call for a graduate nurse whenever illness enters a family, regardless of the economic status. No more neighborhood, lodge
or church nursing care for the sick one. Not only the doctor,
but the family as well have come to believe that professional
nursing care in all cases of critical illness is a necessity, thus
creating a part of the problem in the present day question, the
high cost of illness.
Many new fields of opportunity for nurses have presented
themselves; several new positions have been developed in the
institutional field. Public health in its many branches, including county, visiting and hourly service, is rapidly expanding and
filling a real need, besides the very free use of graduate nurses
for "specialling" in most of our hospitals. With all these added
it might appear that the profession could not keep ahead of its
opportunities, and such is the case. The age of specialization includes the nursing profession and we are not able to meet the
demands for nurses specially prepared for leadership in all its
branches.
The young women leaving our schools of nursing have only
a well rounded nursing education and need further preparation
for any position of responsibility or leadership, but the vast
majority of them are not only self-dependent but often have to
help care for some one else, so that the need of money is urgent
by the time they graduate. Many of them would gladly go on,
but their financial responsibilities preclude it, until finally, their
enthusiasm ebbing, they definitely become a part of the group
65 of stand-stills. Nursing education has not offered the same opportunity for advancement to these young women that they
might have found had they selected some other vocation. Scholarships and Loan Funds have been very few. Then ,too, they are
more tender in years, whereas the nurse of yesterday had often
already encountered blent sunshine and sadness and could much
better withstand the difficulties and hardships to reach her
chosen goal, as proven by the fact that women of mature years
and a wealth of experience are still striving for further academic
knowledge.
Hospital boards of trustees or directors, educators and the
laity are all being awakened to the vivid realization that all
schools of nursing are not equally good and that there is a wide
variance in the quality of service given by their professional
nurses. Each want the best for their community, but they are
learning that the supporting magic wand wielded by hospitals
for nursing education cannot longer continue and that provision
for it must come from some outside source. A curriculum that
is more nearly uniform so that the term Registered Nurse will
mean that a prescribed course of study, acceptable to educators,
has been met, will undoubtedly be developed, and will prove
self-limiting to a certain extent. This will place nurses on a
social plane commensurate with their education and they should
have a right to expect an income sufficient to meet it with
enough margin for the proverbial "rainy day." The changing
viewpoint nO longer regards nursing as a decade vocation. Instead it has become the pregressive work of a lifetime.
In conclusion I would call attention to these points:
1. That the supply of nurses more than equals the demand
for their services, and that the "survival of the fittest"
applies here as elsewhere.
That schools of nursing are becoming real educational
institutions.
That the public look upon professional nursing   as   a
necessity in. time of illness.
That the reports of the Grading Committee have interested people in general in nursing education, so that
Boards of Trustees and Hospital Administrators are
studying their own school of nursing problems.
To the new fields of opportunity presenting themselves
for nurses.
To the lack of equal chances for advancement in nursing education as compared with other vocations.
To the need of a uniform curriculum acceptable to educators.
66 In view of these points, can there be any doubt that this is
indeed a Changing Nursing Era?
Chairman: Is there any discussion on this most interesting
paper ?
MR. McVETY: I would like to ask Miss Davis if it was one
of the conclusions of the Grading Committee, to which she has
referred, that there is a surplus of graduate nurses in the United
States, and if the answer is in the affirmative, what percentage
of unemployment exists on the average throughout the year?
MISS DAVIS: I think from the facts submitted to the Grading
Committee they claim there is a surplus of nurses. For the past
three years in Seattle there has been an average of from 33 to
50 per cent unemployment. I think that in some of the larger
cities they claim there is from 25 to 33 per cent unemployment
throughout the whole year.
MR. McVETY: Is the solution of that problem the abolition
of training schools in some hospitals, or the reduction of the
size of the schools in the larger hospitals?
MISS HENNINGER: I think there wiU be something done by
the graduate nurses and that the larger hospitals will be asked
to reduce their number of pupil nurses.
MISS SWOPE: Might I answer that from the figures of the
Grading Committee? In Doctor Burgess' report she showed that
if all schools of 50 students were closed it would affect the output of nurses a very little bit less than 5 per cent. That before
we can effect the oversupply of nurses, we must reduce the
schools who have more than 50 students and particularly the
larger schools, if we are going to stop this overproduction. As
it is now, we are creating an excess of nurses and are graduating nurses into a field already overcrowded. It is the larger
schools that must be reduced in the number of students that they
are carrying. Dr. Burgess' figures show that in a field that is
saturated at the present time, in the next ten years between
fifty thousand and sixty thousand nurses will be graduated into
this field, unless radical steps are taken to reduce the number
of students in the schools. The American Medical Association
something like twenty-five years ago recognized this fact and
reduced their schools until there are now less than one hundred
recognized schools, and at the same time they raised their stan-
'dard, thus stopping the overproduction of graduate physicians
into a field in which there would not be work for them.
MR. McVETY: What finding did the Committee make in regard to the nurses who left due to marriage and what percentage
67 of graduate nurses are neither competent or wiUing to accept
institutional work?
MISS SWOPE: Doctor Burgess, who is making this report for
the Grading Committee, took this point up at the American
Nurses' Association meeting in Milwaukee this year and stated
that the marriage of nurses has made very little difference in
the field of unemployment as many of them continue to nurse.
MR McVETY: Then the second question—what percentage
of graduate nurses are either willing to accept institutional work,
or are competent to accept it? My experience is, that many
graduate nurses are quite enthused about private duty but do
not enthuse very much over institutional work.
MISS SWOPE: This report also shows that the number of
competent nurses may be somewhat limited, but it is not limited
as regards the number of competent nurses available for institutional employment, but the figures accumulated by the Grading
Committee show that many institutions expect to pay a nurse,
who is able and fully competent to do institutional work, a salary on which she cannot live and maintain her place in a professional field; they offer salaries as low as $60.00 per month
and maintenance. An average salary for institutional nurses is
from $80.00 to $90.00 per month and maintenance, and she cannot maintain her professional standing and her cultural standing and further her education as she should do, unless she receives a salary which will enable her to do so. These figures
are affecting the possibility of obtaining really competent nurses
for institutional work.
CHAIRMAN: About eight per cent of the nurses get married
two years after training, but as stated by Miss Swope a great
number of them continue to nurse after marriage, which does
not affect the question of unemployment. I think another reason for the question of the number of nurses seeking private
duty is the fact that unless they have had some preparation for
the different fields of hospital service they are handicapped and
find it easier to follow private work.
MISS FAIRLEY: I think that the lack of special preparation
the head nurse is one great weakness of our profession. The average head nurse has a tremendous responsibility. I think a more
experienced head nurse is one of the most immediate solutions of
our training school problem. I do not know what Mr. McVety,
means in regard to the ability of nurses to accept institutional'
positions. I am afraid in the last year or two that the unemployment among the private duty nurses has tempted a number of
graduates to apply for institutional positions who are not really
68 interested in institutional work. They are merely interested in
permanent employment and in a regular salary. I think that is
a point heads of hospitals should stress very much, that in accepting nurses for general duty we should find out whether she
is really interested in institutional work, especially in regard to
her example to the student nurse. At the present time the.
change in personnel in hospitals is colossal and in the training
school it is a very serious thing. You will find a teacher in a
public school who has held the same position for probably twelve
years, whereas, in a school of nursing, you will find the head
nurse has held the position for twelve or eighteen months, and
if she has been there two years we consider her an experienced
woman.
DR. WARNER: We found it impossible to train nurses during
their student training in special institutional work. The nurse
is supposed to have so much time in every department. We
find as they go on that some nurses are specially adapted for a
certain line of work and will develop, say, into surgical nurses
or supervisors of different departments. It is difficult, however,
to give them the amount of training they would like to get in a
special line and at the same time give them an all-round training
in all of the other departments. I wonder if it is the practice
in many institutions to use seniors as supervisors or assistant
supervisors by which they may have some training and development in the management of hospitals; also whether the course
could be made flexible enough to have a nurse major in some
departments, something they want to develop in, or must they
go through the whole course of routine without any deviation?
MISS DAVIS: I think you will find in the Course of Study in
most schools that the student's time is mapped out from the
time she enters the school until she graduates, in a definite rotation from one department to the other, but you will find it is
possible to have about six months of that time which can be
used in some department in which the student has shown a special aptitude. I consider it is unfair to our patients to have
eighteen-, nineteen- or twenty-year-old girls left to do the supervising because, after all, they have not had the experience. I
think it radically wrong from the standpoint of the patient and
from the standpoint of the nurse because she is not prepared to
meet that obligation.
CHAIRMAN: The frequent changing of the personnel of the
hospitals I think is one of the biggest problems the smaller hospitals have to meet. I do not think we recognize merit sufficiently from the point of view of salary. It seems to me that the
idea is prevalent that because there are a large number of nurses
69 available they can take almost any person in and put her in
charge of the ward. I think the living conditions in some of
our hospitals are not sufficiently attractive to hold properly
trained nurses and in the smaller communities it seems very difficult to retain properly trained and efficient nurses.
MISS RANDAL: Would some person tell me in what other
group do they expect that, because a nurse has a diploma, she will
naturally make a success as an executive or supervisor? No
matter what group of people you take there is just a small proportion who are able to fill executive positions, so why should
we expect more of our graduate nurses?
CHAIRMAN: We shall now have a paper from Miss Clara E.
Jackson, R.N., Superintendent King's Daughters' Hospital, Duncan, B. C, on:
"SHOULD THE SMALL HOSPITAL CONDUCT
A TRAINING SCHOOL?"
MISS JACKSON: I have been asked to speak to you for a
few moments on "Should a small hospital conduct a training
School?" I am not prepared to answer that but will put forward
several items for your consideration and perhaps someone with
more experience than I have will be able to solve the problem.
I will endeavor to bring out the weak points as well as the good
ones. When we feel we are perfect it is then time to step out
and let someone else carry on. If we can bring to light at a
convention like this our weak points, there will be hope of our
position being strengthened and of out difficulties being solved.
For the past four years I have been trying to find out for
my own satisfaction whether the small hospital is justified in
conducting a training school or not. When I say small I mean
50 to 100 beds; under 50 beds I don't see how they could without extensive affiliation. There are a good many angles to consider and one cannot decide in one day or even in one year, nor
can one hospital decide for another.
We will divide the question into six divisions and will take
each one in turn for a few moments:
The Patient;
The Nurse Herself;
The Board of Management;
The Doctors;
The Superintendent;
The Public.
70 The Patient:
The patients being paramount, we give our first thoughts to
them. To my mind the patient receives more individual care,
there exists a much closer co-operation with treatments and
medications and a keener interest is exhibited even, in small details where the nursing is done by the student nurse. She is
working up to something, keen to do her part, and to do it so
thoroughly that it wiU meet with approval. She is desirous of
being commended beyond her fellow pupils. Amenable to discipline, both on and off duty and the rule existing of "10:30
P.M., lights out," she comes on duty fresh and ready for work
in the morning.
The general run of general duty nurses do not like to be
disciplined either on or off duty, and take a delight in staying
out until midnight. Having been trained one way, they do not
so easily adapt themselves to other ways; they have not the interest of their patients so fully at heart; they are not working
up to anything; they are not competing with others for approval of work. Often they do not wish to look after certain
types of cases; they will pack up and leave if things just don't
go their way.   Why do we so often get this type of nurse ?
The hospital training nurses each year puts on its own list
for executive positions those of its own graduates, who have
proved worthy. Others, who are outstanding and who are not
taken up by their own hospital due to lack of vacancies, are
recommended to positions of trust elsewhere. Those who are
excellent special nurses, but not good executives, are also in
great demand. The public health field draws those interested
in that branch. It is then usually the type not suitable for any
of the foregoing fields that drift from place to place and on
whom the small hospital would have to depend for its reputation
of good nursing and cheerful service—and each hospital naturally is desirous of giving the best.
The Nurse Herself:
Are we doing full justice to the nurse herself?- Is she getting the training that will stand her in good stead out in the
world? Can she take her place with a nurse graduated from a
larger hospital and not feel embarrassed? If you were a very
sick medical case requiring skillful nursing, would you be satisfied that sueh a graduate could handle you skillfully and efficiently? If you had a major operation would you trust yourself to her care?
Now, what can the small hospital give her ? How can we
be sure she is getting the proper training?
71 First, we must make sure we ourselves are keeping up-to-
date, that our class-room work is in line with the large hospital,
and that on entering she is taught the fundamentals, of nursing.
Here is where I think the small hospital can give more. With
fewer students closer supervision can be given, and a teacher
can give more individual tuition to say six or eight than to
thirty or forty, and not only teach a treatment but work with
that student until she does it well. The classes being more intensive, the student should receive greater benefit. On the wards
the instructor and superintendent, having fewer students, can
give closer attention to ward supervision, correcting mistakes in
procedures earlier. Being fewer, one is more likely to notice
the inattentive or unadaptable one and if a little extra coaching
does not bring forth response she does not go on to become a
slacker in the profession.
Having made sure of proper teaching in class, and supervision on wards, one now turns to her practical experience. And
having practised the arts of nursing in the class-room we must
see she gets sufficient of each branch to make her efficient. This
can be done by the same routine of posting for various services;
by the nurse herself keeping a record of all her cases, and number of days she has nursed the same, this record being checked
by the supervisor and turned in as permanent records at the termination of the service. The last six months of her three years
can then be given to the type of cases in which she has received
little training.
We will now see just what we ean give her in practical work
compared to the larger school. In a pediatric ward in a large
hospital there may be found five or six nurses say to twenty or
thirty patients, out of these six, two or three would be juniors
who would be making beds, filling ice caps, hot water bottles,
feeding the child who has a tray and doing the general tidying.
Then there would be two intermediates who would be responsible for bathing of children, giving treatments, doing dressings
and feeding the smallest babies; the senior nurse would attend
to meals with help of others, take temperatures,, give medicines
and do the charting. In a small hospital there exists a ward of
six to eight beds, averaging say five patients. One nurse is
posted who admits patients, gives baths, makes beds, gives treatments, medications, does dressings, attends to meals, feeds any
child requiring feeding, does her own charting, keeps clean her
own departments, reporting to her supervisor even to the smallest
spot found on a child. And whilst she perhaps does not handle
as many children, she does much more for the ones she does
handle.    It is always an advantage, if she is having a patient
72 operated on and can be spared, to allow her to see the operation. To my mind that nurse gets as much, if not more, from
that three months than the nurse in the large hospital.
Now we will take another important branch, the operating
room. In a large hospital there will be ten to fourteen student
nurses taking a two or three months' training. Probably one
week would be spent in learning the names of all the instruments
and care thereof, gloves and how to repair and prepare, attending to plaster cast cases, keeping up supplies; one week in cystoscopy, then on to nose and throat service; another week in
eye department and perhaps taking an odd minor scrub case;
the last three weeks spent in scrubbing for general surgery.
I don't know what would be the average number of cases this
nurse would scrub for, but I would estimate it from thirty to
forty. She would also get some outdoor service where she would
attend clinics and minor accident cases. A small hospital, on
the other hand, has one student nurse with an experienced supervisor who can give her whole time to training one nurse. The
first month she is trained in the use of instruments, in scrubbing
up and draping an imaginary patient, making of solutions, care
of gloves, and attends to minor accidents and any outdoor case,
also attends as unscrubbed nurse to any scrubbed ease; during
the second and third months she scrubs for all cases, major and
minor; during the fourth month, whilst the next nurse is getting
her month's preliminary training, she goes from the ward to
the operating room to take any case needing a scrubbed nurse,
and in this way gets three months' intensive and one month
partial training averaging 60 to 70 scrubbed cases and 60 to
70 unscrubbed cases besides plaster cast cases and many outdoor
cases.
There is this difference however — in a large hospital,
doctors work on time and quickly, others are wanting the operating room, whilst in a small hospital, not having that pressure they often keep the operating room staff all ready scrubbed
and waiting, and some seem to have no idea of time or system,
therefore, in the small hospital efficiency with speed is harder
to instil into the nurse.
"What about nursery and maternity," you will say, "Two
very important branches?" A large hospital gives from two
to three months combined service somewhat as follows:
3-4 weeks ward duty in Mothers' Ward
3-4 weeks ward duty in Nursery, when formulae would be
made up.
3-4 weeks Case Room, 20-30 cases.
73 The smaller hospital, say with six to eight beds and the
same number of cots, has one nurse who is given two months in
the nursery alone. When the nurse receives her baby marked
from the case room, she admits it, marks its cot, cares for each
baby throughout, makes up any formulae and is solely responsible for everything in connection with her babies and nursery,,
including charting. The supervisor, having only one nurse in that
department, can give individual tuition. Another two months
she spends in the maternity wing where she has care of the
case room and all mothers. She admits, prepares, watches progress of, and assists in the case room, attends to baby's eyes,
marking it and placing it in the nursery. She gives daily care-
to the mothers, taking temperatures, does her own charting and
treatments and finally escorts her patient to the door when leaving the hospital. She is called for all cases during her two months
and averages 20-30 cases.    This, I feel, is a complete service.
We pass now to communicable diseases. In a large hospital
there usually exists floors or departments for each type of disease. From two to three months is spent, first in one department, then in another, perhaps a week or two with each disease-
A small hospital will have an isolation building with say six
to eight beds. Here the nurse admits any type of infectious
disease, giving daily care to each, serving meals, charting, finally
discharging and doing necessary terminal disinfection — having
to be very careful that she is not the cause of cross-infection.
The nurse in this case gets more the training she would need in
a home, but does not by any means,, get the experience in these
diseases the nurse in the large institution gets. In smaller centres when there is an epidemic, as sometimes there is, instead
of the nurse getting that experience which she would so much
appreciate, the hospital isolation is filled with the few and the
rest have to be cared for in their homes. The people in the small
cities do not take the responsibility; the hospital cannot afford
it, and perhaps the fact of these people being nursed in their
homes is the reason for the epidemic.
The diet kitchen which plays a great part in nursing now,
leaves a great deal for thought. The large hospitals have experienced dietitians. The nurse will spend say two months in that
department, first on general diets, then on special. In a smaller
hospital, sixteen classes in junior cooking are given, and very
thoroughly, too, but there is little in the way of special diets, and
being a small hospital it does not usually boast a dietitian. The
senior classes on diet and disease are given . What can take the
place of the two months practical work in the diet kitchen itself?
As there is no dietitian each nurse under the direction of her
74 supervisor prepares her own trays for her special diets for the
patients under her care throughout her three years. During her
two months night duty in her first year, being a relief nurse not
responsible for any ward, she sets the patient trays for breakfast, cooks supper for the night staff and makes the porridge
for breakfast. Whilst all this is very helpful for her future I
feel more could be done with a dietitian and a two months'
course in the kitchen.
In surgical nursing she gets a good training; in medical
nursing she gets a fairly good training; in nose and throat work
good; in gynecology, good; in ear cases, good (mastoids good but
few, 50 per cent, going to larger centres, 50 per cent, have a
specialist come to operate at the smaller centre).
The Doctors:
The doctors are a great factor, for no matter how much
teaching is given by nurses, there remain those lectures which
only a doctor can give — the other view of things, their point
of vision, to make it complete. In large hospitals there are doctors who specialize in all branches and can bring that specialized
experience to the nurses, which has untold value. Having many
to draw from, you naturally select the ones who can give best
value and they, being experts in that line, are pleased to give
and honored to be asked. Therefore, the ones who do not wish
to lecture, the ones who feel nurses are getting too much theory,
the ones who though good themselves are incapable of transmitting knowledge, are not felt. Whereas, in a small training
school, say you have six to eight doctors, none specialists in any
line, but all good practitioners, and all being interested in and
doing better in one branch; one-third will give regular lectures,
are keen themselves, and good teachers; one-third like to be
considered on the teaching staff, but make a big fuss about ten
lectures a year, and are always going to give them but not
taking it at all seriously; one-third would like to teach, realize
the necessity, but are not capable of transmitting knowledge —
leaving just one-third, two or three doctors upon whom you
can absolutely rely.
How can the small hospital meet this deficiency? The only
way that I can see is by having your instructor give a course of
lectures in the doctor's subjects, and then taking from the doctors what you can get, but not depending on them. The question
arises — if the instructor of nurses is covering those subjects
thoroughly, are we handicapping the nurse or not, by fewer lectures from the doctor? I am inclined to believe that it is better
to have a well-thought-out class from an instructor of nurses
75 than a half-hearted one from a doctor, but that doctors giving
good lectures, whole-heartedly, give invaluable aid to the nurses.
The lack of histories and proper writing up of cases is one
to my mind interfering a great deal with the progress of a
nurseJs training; of so much value to the patient, and invaluable to the nurse in her care of patient, it seems that the upkeep should be made legally compulsory.
The giving of made-up prescriptions is another draw-back,
as some doctors act with a medicine prescribed as though it
were a secret invention of their own, and as though a nurse,
knowing the contents thereof, would deprive them of some valuable rights. The doctors who wish to be of greatest value
would scorn to have any such secret, but would wish the nurse
to realize that it is a serious thing to administer that which she
knows not of. Lectures, histories, prescriptions, then are three
things which give the small hospital cause for deep thought in
the training of its nurses.
The Board of Management:
Now, we will take the responsibility of the Board of Management, whether it consists of the type of persons who realize
that a person cannot be an efficient nurse without knowledge,
and that knowledge cannot be gained without a teacher, and
that it is impossible for one person to do the teaching and
administer the hospital — or whether it consists of members who
appear to have no such knowledge. How many board members
would send their children to a high school or university and be
satisfied for them to work around with no definite plan of
tuition? Or how many would be content to leave their children
there, when there was only one teacher, and that teacher with
many other duties? Many are just as keen as we are and do
realize their responsibility, but it is surprising how indifferent
some members can be, how some look at it as a matter of finance,
and say "If it is cheaper we will have student nurses, if not,
get rid of them, or let the superintendent do all the teaching."
No thought as to what is the best service for the patient, no care
whether the nurses are properly taught or not, so long as it
is cheap and the work is done. No matter whether you have
a training school or not, to provide efficient nursing care is
not going to be cheap. We must have board members who wiU
realize that better training means better nursing, and they must
be just as keen on advancement as we are ourselves.
The Superintendent:
It depends so much on the kind of person she is — whether
she is going to be persuaded by her board members and doctors,
76 that so many things are not necessary in a small hospital, or
whether she is going to play the game by her profession, upholding the dignity thereof, and in spite of all opposition doing
what she knows is right and seeing that the student nurse gets
at least the minimum of lectures and experience. To do this
she must have an instructor of nurses. In a small hospital the
superintendent of nurses is superintendent of the hospital as
well. That is, she is the administrator, the purchasing agent,
housekeeper, supervises repairs, home, social life of nurses, possibly does all the cutting out for articles to be made, plans and
organizes all improvements, to say nothing of the numerous
calls from the public from time to time. How then can she be
responsible for so much teaching, so many classes without the
help of an instructor? It is her duty, if needs be, to fight to
the very limit of her power for her patients, nurses and hospital. Who knows better than she who has herself been a probationer, survived the arduous tasks of training, has been taught the
use, care, and expense of every article used in the hospital together with its value; has worked her way up through every
department, managed many in the absence of a sister or supervisor, has reached and' passed the supervisor's position and has
been recommended to a hospital? She is not doing something
she has never done before, but something she has been trained
to, has lived with for years, and has become part of her. She
brings to you a service of value, a priceless treasure of experience, to work out your problems, to help you surmount your
difficulties. She is not fighting for herself but for the better training which means better nursing for your hospital, and she needs
your support wholeheartedly.
The Public :
Can we conscientiously, after graduation, let that nurse go
out into the world feeling that she can give an efficient service to the public who depend on and trust her, who will seek
advice, and will watch her methods? Can we feel that lives
can be trusted in her care, perhaps far away from a doctor, sometimes during tedious hours of danger, maybe not near a phone,
often through long, weary nights ? It is no use training her only
for our supervision, only for the district the hospitals stand in,
but we must visualize many places, many sicknesses, many conditions and examine ourselves closely as to whether we are sending her out equipped to meet these emergencies.
The public are dependent on us, as leaders in hospital work,
to conscientiously equip our nurses to give the best service, both
in the hospital and out in the world, and we must not be found
unworthy of that great trust.
77 CHAIRMAN:   The paper is now open for discussion.
MISS HENNINGER: It was a very able presentation of this
subject and I feel it was discussed in a very thorough manner. I
feel that the Superintendent of a hospital trying to have a school
for nurses has a very responsible and far-reaching position. I
feel that as the Superintendent has so many duties, she is often
times handicapped, and it seems to me it would be found after
counting the cost of conducting a small school for nursing with
the necessary amount of instruction given and the time allowed
for doing so, that it would be found the cost would far exceed
the cost of having graduate nurses. Miss Jackson also brought
out the point of individual instruction, the nurse taking care
of the patient individually and thereby obtaining a better knowledge of the disease and its treatment. I feel that can be carried out in a larger school by having the same system of taking
care of the patients, so that the benefit that was pointed out in
the smaller hospital could be also given in the larger hospitals.
Then there is the point of teaching the special classes, because
it is difficult on the small staff in the smaller hospitals to have
doctors who are able and willing to give the nurses the necessary
information. All in all, Ut seems to me the smaller hospital is
finding it a harder and harder problem to1 conduct a school that
can turn out satisfactory graduates for the community. I believe this nurse might do very well at private duty nursing,
but I think her usefulness in larger institutions or in public
nursing would be quite limited.
MISS RANDAL: One very weak point is the fact that no
person knows what is meant by the small hospital. One will say
that under 50 beds is a small hospital and another person will say
that 50 beds is a small hospital, and the problems are not the
same. A small hospital board does not supply the proper equipment to carry out a well thought-out and well-planned course.
The dietitian is absent, the instructor is rare, so it goes on
through the whole story. And while I think that was a very
beautiful picture of an ideal training in a small hospital, I do
not think you will find in actual real life it can be worked out
in the same ideal manner.
MISS SWOPE: I want to thank the speaker, I think she gave
a very comprehensive view of the small school, but I am interested in one of her earlier statements, that apparently it is the
belief that the patient will get better care from the student than
from the graduate nurse because she is more interested and
because she is more disciplined. But are we not talking of the
same person — they are not two different people — but the
same woman in two periods of her life?    One period is her stu-
78 dent period and the other is after she has graduated and received
her pin and has been told that she must assume responsibility;
and yet we say, she is no longer responsible, she is no longer
interested. Yesterday we heard Dr. Agnew say that hospitals
and particularly the smaller hospitals should provide meeting
times and places for their medical staff. Why? Because these
men are going on and are interested in their work and he is
asking for the co-operation of the hospitals in the further professional development of these men. I wonder how many hospitals give any thought to the professional development of its
graduate staff of nurses. Why should not the staff of nurses
be brought together in a meeting and hear from the superintendent or the members of the board the nurses' responsibility
to the property of the hospital and their responsibility to the
patients? I think this is one of the weakest spots in the organization of our staff. We should make these women feel that
they will be able to grow and develop in our institutions and
that we will expect from them the best they have in return.
We should say to them "we are going to make it worth your
while in professional development as well as by increased remuneration. ''
DR. ALEXANDER: I was very much impressed with what
Miss Jackson said in regard to the teaching by the doctors. We
have a very good General Hospital in Salt Lake City and we are
the teaching school hospital for the University of Utah, and
even with the teachers in the University on our staff, we still
have some trouble when it comes to teaching the nurses, so
much so that the Superintendent of Nurses has been compelled
to give one course herself, so if that conditions exists in the
larger cities, certainly the smaller hospitals have nothing to
feel ashamed of.
CHAIRMAN: We shall now hear from Miss Helen Randal,
R.N., Vancouver, B. C,, Registrar British Columbia Nurses' Association, who will speak to us this morning on
"AFFILIATION OF THE SMALL SCHOOL OF NURSES
WITH THE LARGER SCHOOLS"
MISS RANDAL \ Affiliation as referring to Training Schools
may be defined as the rounding out of the nurse's professional
education in one or more schools of nursing, other than the one
from which she graduates. All deficiences in schools of nursing
affect all employers of nurses, whether hospitals or the general
public.
Nursing education in the smallest schools must of necessity
follow the  recognized  curriculum  in  all required subjects,  in
79 order that all graduates may obtain their standard of Registered
Nurse, and enter the profession with no handicap. In order
to do this the schools which cannot provide adequate training
in all departments must affiliate. Success in the nursing field
is due to the student nurse, so far as the hospital can give it,
and to the student in a small hospital affiliation is the solution
of the problem presenting itself.
In British Columbia affiliation came into existence in 1913,
at the Vancouver General Hospital, upon the application of a
keen, far sighted superintendent of nurses in a small hospital
who felt that her graduates were not getting what they had the
right to expect from a school of nursing. The hospital board
allowed the experiment and a course for the third year was carefully planned to take care of those students, and to give them
theory and practice in what they lacked. This has continued
successfully ever since, to the united benefit of both large and
small schools. Students of both hospitals are alert, "on their
toes," in a friendly competition to show the best of each school
to the other.
It has been a great satisfaction to know that affiliates have
been welcome in the Vancouver General Hospital, and that there
is almost as deep a spirit of loyalty on the part of affiliates
to the Vancouver General Hospital as to their home school. One
happy touch is the invitation to superintendents of small training
schools to be present at the graduation exercises of the Vancouver General Hospital, and to present diplomas from their
schools to their own graduates. Careful questioning of affiliates shows a warm feeling of gratitude.
That there are difficulties in arranging such a course is true,
but the benefits outweigh them from our experienee. One
difficulty is the irregular sequence of students coming to large
schools which upsets the schedule of the latter naturally, but
the appointment of a stated time in each year when a class of
affiliates may enter has helped much.
The affiliates have made good, and because of combining
the best in both types of hospital have been successful. The
graduate of this combined course has been particularly fortunate
as she gets the benefit of the personal attention of the superintendent in small schools, and the closer personal connection
and responsibility that is part of the nursing in small hospitals
where the patient is a personality and not a case or occupant
of a certain bed or room, as well as the greater experience found
in the larger hospitals.
Just when, in the course, this affiliation should come is
a question.   We find it easier to manage if the last year is used
80 for this purpose. The course is planned individually to strengthen the weakness in certain departments of small hospitals —
notably in medical nursing, pediatrics, infectious nursing and
dietetic departments. The affiliate entering as third year student gets maintenance and allowance from the larger school,
otherwise she pays her own expenses.
A special affiliation for a shorter time is needed badly by
the smaller — not the smallest — training schools; notably in
pediatrics, infectious, tuberculosis and, in some, the dietetic department. Tranquille Sanatorium is most generously arranging
for a two months' intensive course in the nursing of tuberculosis, which we hope to have in force before long.
That there are weaknesses in the large training school as
well as in the small one can hardly be denied by thoughtful
observers. Mechanical nursing, lack of personal interest in the
patient, avoidance of responsibility, is admitted. This may be
helped by case studies, better supervision and closer personal
contact with the patient.
May I venture to bring to you the hope that we may be
able to establish a better scheme for all types of training school.
Please remember, if this plan sounds almost impossible, that the
so-called impossibilities of the past are now well established,
every-day happenings and the "dreams of to-day are the facts of
to-morrow. I refer to the affiliation or staffing of small hospitals
by pupils of large schools, so that they too may have the pleasure and profit of closer contact with the patient and other advantages of the small school. This could be done by establishing regional hospitals which would furnish the staff for a certain number of hospitals for, say, a period of six months.
Increasing the length of the preliminary period,' courses
specially arranged for those interested in nursing to be taken
in the High Schools, and higher educational standards for entrance into training schools, should enable much of the theory
of the curriculum to be completed in the first eighteen months.
The affiliation period would follow, presumably, between
the 18th month and the middle of the third year. What a tremendous help to the small hospital it would be to have standardized nursing technique established, and how much easier the
graduate would find the work in various hospitals if she discovered that they all had the same technique.
This would also help to reduce the number of small training schools, except as departments of the larger regional training school.
81 These graduates, having experience in both types of hospital, would surely feel more confidence in undertaking almost
any form of work in any hospital, would be more adaptable
and responsible and thus the best type of graduate would be
brought back to our midst. I feel certain that the time spent in
our small schools would be among the bright spots of the pupil's
life. With our comfortable nurses' homes all over British Columbia, uniform educational (minimum) curriculum and preliminary education, which we have now, why not follow to a logical conclusion the standardization of the nurses' training — each
regional mother hospital being interested in helping the smaller
one, and with extra expense as to instruction in the small school
gone and supervision better, a more generally useful product
of our training schools would be the result.
If we get the larger vision, and "where there is no vision
the people perish," may we not see much that is good in the
scheme. Difficulties — many of them in other directions —
have been surmounted; let us not feel that this is insurmountable.
CHAIRMAN: Is there any discussion?
MR. McVETY: How small a hospital measured by bed capacity and equipment should be permitted to conduct a school of
nursing, the nurse to spend her last year as an affiliate in the
larger hospital?
MISS RANDAL: I do not think you should consider the bed
capacity. It is the service you get and on that point we cannot really judge by the size of the hospital. Personally I think
anything under 50 beds should be a third-year course, and only
then if they give private service.
MR. McVETY: How many hospitals in the Province of British Columbia are accepting affiliations?
MISS RANDAL: The full year's affiliation has been restricted to the Vancouver General Hospital school. We have not very
many,training schools in this province.
MISS HENNINGER: I wonder if the number of affiliations
from small schools are in excess of the number the hospital can
take care of.
MISS RANDAL: I do not think there has been any difficulty
in the Vancouver General Hospital in fitting them in. There
are five or six probably in at a time but not any more than that.
MISS FAIRLEY: I think one of the difficulties is the lack of
continuity from the smaller schools. When the year is up the
next group is not ready to come along. That is one of the most
difficult problems of the affiliating school.    I can see it from
82 the point of view of a small hospital, it depletes their staff and
my sympathy is with the small school. I think, however, there
should not be a gap between one group and the other.
MISS JACKSON: I would like to ask Miss Randal if the
larger hospitals could send extra nurses to the smaller hospitals
which they could carry for the time being. If these nurses could
be sent in exchange that would solve a great many of the difficulties for the smaller hospital.
MISS HENNINGER: I was particularly interested in that
aspect of Miss Randal's address this morning. I wonder if it has
been tried out in the States.
MISS PHELPS: I think it is a practical thing to do and it
would help the smaller schools and assist the nurses in acquiring their education and also perhaps be the means of overcoming
some of the difficulties we have in sending out students who do
not fill the bill.
DR. ALEXANDER: Let me qualify Miss Randal's remarks.
She intimated that the small school was getting more than the big
school and I disagree with her there; I do not think the small
school is getting more than the larger school because of the fact
that in the big centres it is difficult to get nurses in our general
hospitals. That is the most difficult part of the whole situation. I do not want to start any hospital quarrel, but I cannot help but feel that the nurses in training in the General Hospital get a far better training and are turned out as better qualified nurses than from any private institution. The nurses who
go out to do general nursing work are nurses who must be qualified in almost every line and every department, whether it be
the handling of epidemics, mental cases, tuberculosis, etc., all
down through the line. That is what I called a really well
qualified nurse. These nurses who are affiliated with our hospital are paid exactly the same. Miss Randal has given us a very
wonderful idea when she said that these young women are
graduated with the other students and are given their diplomas
by those in charge of their own smaller hospital. This has
given me a good idea and I certainly shall remember it and
when I go back I shall see if it is not possible for us to put that
into effect.   It certainly is a very big thing.
MISS PATTERSON: We have an affiliation throughout the
hospitals in Seattle and we find it works out very nicely indeed.
We take in these extra students and we pay them the same
allowance as is given them in their own school. We house them
but they bring their own uniforms and are under no expense
to their own hospital.    At the beginning of the fall terms we
83 intend to extend our course giving a four months' course. During this time they will get the theory as well as the practical
work and the students will not return to their schools for any
other instruction, which we hope, will work out better than in
the past.
CHAIRMAN: Our next speaker is Sister John Gabriel, Seattle, Washington, Educational Director for Schools of Nursing, Sisters of Charity of Providence in the Northwest, who will discuss
the question of:
"NURSING EDUCATION"
SISTER GABRIEL I Mary Roberts Rhinehart recently published a very inspiring article to which she gave the title "In
Praise of Discontent.'' Perhaps many of you read the article; it
appeared in the December number of "The Ladies Home Journal." In this article the author reviews the advantages derived
from becoming normally discontented from time to time and she
stresses the fact that lazy people never have this experience; they
may become irritable, resentful and rebellious, but eventually
they will aceept things as they are rather than put forth the necessary energy to change them. It seems to me that the nursing
profession is at this time going through a period of honest, wholesome discontent in which it is not sparing effort to achieve the
destruction of old inhibitions and the establishing of new projects that lead to higher ideals for the profession and better
service for the public.
The rate of progress in nursing education has been too
rapid for everyone to appreciate. Since the year 1860 when
Florence Nightingale opened her first school of nursing in London, and later in 1873; when the student nurse became an entity
on the North American continent, nursing education has passed
through a number of different phases, so that to-day it is a long
distance from where it came into being.
From the beginning, however, nursing education served the
dual purpose of caring for the sick and educating the nurse.
After over fifty years of experimenting with this system of
nurse education and as a result of careful expert investigation
covering a period of twenty years, the nursing profession has
arrived at the conclusion that the school of nursing in a large
number of cases, is not turning out a nurse that is prepared to
meet the changing needs of the present day; nor to measure
up to the level of the finished products of other professional
schools.
While the professional status of the nursing group has been
generally recognized, for some time, there are still those in our
84 midst who question it on the basis of the educational and cultural background of some of its membership; therefore, one of
the highest ambitions of leaders in the nursing profession at this
time is to remove this stigma and leave no doubt in the mind
of the public as to the professional fitness of every one of its
members. These women are convinced that the realization of
such an undertaking will depend largely on the ability of the
nursing profession to control the education and training of the
young people who elect it; consequently ways and means of
raising the standards of entrance so that only the superior individual can meet them and the building up of a curriculum to
meet the level of other professional schools forms the very interesting theme of every paper and discussion throughout the
United States and Canada to-day wherever nurses and others interested in nursing education meet.
There are those Who endorse the advances thus far made
by the nursing profession and there are those who resent them.
The fact remains, nevertheless, and it cannot be denied, that the
educational background of the applicant to the school of nursing has not been made as important a factor in admitting students as it has been in other institutions giving professional
training; whether this was an oversight on the part of the profession or a pressure on the part of the institutions controlling
schools of nursing, it is evident that the entrance requirements
in nursing schools have not kept pace with the progress made in
other institutions of learning.
One or two years of high school instruction is a very inadequate preparation for the intricate and technical subjects that
fit one for a profession. The word "profession" carries with
it an implication of higher education and refinement of manners
that is an evidence of the development of powers of the mind
above the average. It is the experience of hospital administrators and nurse educators that the student with but one or two
years of high school to-day is of a type that in most cases rarely
ever reaches a high degree of efficiency, and in looking up such
a person's record one will find her to be an individual who
interrupted her school work because she would not put forth
the effort necessary to measure up to the level of her capacity
or she did not have sufficient intelligence to permit her to carry
the subjects outlined in the curriculum. It is obvious that such
an applicant is either dull or lazy, possibly, too, she may be influenced by the delusion that in a school of nursing she will
be relieved of the responsibility of any further study. The restlessness of the adolescent, at this age, may also provide a motive
for a change and be a tributary cause for a student's breaking
85 away from her studies at this time, when if the school of nursing were not open to receive her, an adjustment might be made
that would carry such a student to the end of her four years
of secondary work with satisfactory results.
Institutions are receiving such applicants quite satisfied that
they are meeting the legal requirements of their State or Province. While one or two years of high school is the minimum
entrance requirement for schools of nursing there will always be
a good number of people who will aim no higher. The mass of
humanity is seeking the line of least resistance and making a
boast of "getting by" with as little effort as possible. As long
as we use the term "minimum requirements," these only will be
met by the larger groups, and as long as the students graduating
from a high grade school are classified on the same level as
those graduating from a low grade school by State and Provincial Boards for examinations leading to a certificate of registration, there will always be inefficient nurses going into the profession.
It is true that much has been achieved through legislation,
but more remains to be done before a sound professional basis
is secured.. New responsibilities are being constantly realized by
the profession that are bringing the nurse more and more before
the public to claim her rights as a professional woman and to
demand the protection and co-operation that such a standard
may reasonably expect.
Old inhibitions must be broken through in order to vitalize
new experiences but this is not always as difficult a task as it
appears to be. In the matter of standardizing entrance requirements for schools of nursing, I think we all agree that a high
school education is the minimum basic preparation for the study
of a profession.
Previous to the Flexner Report on Medical Education in the
United States and Canada, which appeared about the year 1910,
there were a good number of medical schools on this continent
that admitted students with only an elementary education; today evidence of a university background is necessary for the
medical student. The leap from an elementary education to the
university requirement did not seem to work a hardship on a
great many; undoubtedly many suffered the pain of a new idea,
but in the larger number of cases the prospective student could
have gone on through high school and university if the urge had
been present, but the school of medicine was open to receive him
with the equipment he had, such as it was. With high schools
in every town and village to-day, is it not reasonable to assume
86 that the same may be true   of   the   applicant to the school of
The question of separation of the school of nursing from
the hospital is another problem that has been discussed by a
number of educators. The question is of a type upon which all
nurses cannot agree; there are some who hold with John Dewey
that education means "learning by doing,"-and they are convinced that the student can never be totally separated from the
bedside of the patient while she is in training; and there
are others who believe that nursing education has reached its
climax under hospital control and that much of the nurse's education can be better secured outside of the hospital in institutions
of learning.
The mind of the profession seems to be torn between these
two great problems: "To separate or not to separate." If the
final decision is ever reached, and it is in favor of the first, then
it would seem that some means must be provided to enable the
student to establish habits and skills for effective nursing care
in its natural setting. This would call for some sort of interne-
ship for nurses after their theoretical field was covered at the
university, or it might be realized in a highly endowed institution
where such students would be admitted so.many hours a day to
work under very close supervision, but it is safe to say that not
all hospitals operating on their own resources could afford to
give the time of highly-paid service to supervise such a programme. On the other side, if the decision is made in favor of
the second proposition, it is argued that the school of nursing
will still continue to share the weaknesses of the apprentice
system, which seems to have for its ultimate end, service and production as against experience with educational value. Whatever
the answer to the question "To separate or not to separate" may
be, it will bring about important strides in the, education of
nurses in the near future and steps in progress will soon be under
way that will toss many a school of nursing on this continent out
of its rut and force it to make an entirely, new adjustment if it
is to bear the name of a professional school.
Leaders in the nursing profession are not only occupied with
the education of the student nurse, but they are also concerned
with plans to complete the basic training of the graduate nurse.
The director of the grading programme in the U. S., Dr. May
Ayres Burgess (and I dare say Dr. Weir here in Canada) has
discovered a large number of inefficiently trained nurses in the
field,—which places the responsibility upon the group they represent to provide the opportunity to bring them up to the proper
level.   To meet this additional duty much has been accomplished
87 and much is still being done in the way of formulating plans and
methods of approach to various outside institutions to secure
their co-operation in putting on programmes that will attract
the graduate nurses who feel the need of enlarging their fundamental training by additional scientific knowledge.
There are many graduate nurses who need to be convinced
that there is no magic in a diploma that prevents things from
progressing beyond where they were when they received it;
neither is there anything in a diploma to guarantee efficiency
for life. Consequently any nurse who is conscious of the fact
that she is losing step with her fellow nurses and cannot hold
her own in service and-professional fitness should take advantage of the large number of lecture courses, clinics, institutes
and college extension opportunities that are available at various
centres in the country and have been thought out for the nurse's
special benefit. Every nurse owes it to herself, to the patient,
to the doctor and to the profession to press forward in the march
of progress and continue to grow.
There is serious unemployment among graduate nurses today. This is a great source of anxiety to the profession, but it
has been pointed out by experts who have studied the economic
situation among nurses that the less highly trained nurses are
the sufferers. They tell us that there are too many nurses trained
for surgical duty and not enough well trained for medical work.
There seems to be a comparative lack of highly trained nurses
for obstetrical work. Alj the 1929 meeting of the L. of N. E. in
Atlantic City, J. P. Kidlock, Chief Medical Officer, Department
of Health, Edinburgh, Scotland, stressed the importance of
longer and better training for nurses in this department, particularly on this continent where the maternity death rate is so
high. There appears to be no question of unemployment for the
well-trained nurse in pediatrics nor in nervous diseases. There
are not enough nurses skilled in diets and communicable diseases.
What shall I say about the demand for qualified instructors,
supervisors, head nurses and laboratory workers? Then there
is the problem of distribution. Nurses, like doctors, are rushing
to the cities and leaving the rural districts to the county nurses
and to the hospital. Again private duty nurses have been multiplying, and the class of people who employ this type of worker
has been relatively decreasing. Preventive medicine is having
its effects; houses are giving way to apartments and there is no
room for the nurse. Doctors are more and more inclined to send
their patients to the hospital. Hospitals in their turn are enrolling more and more students to take care of the rising tide of
patients, and as a consequence they are sending out more and
88 more graduates into an already over-crowded field. The circle
at first sight does appear to be a vicious one. I do not feel, however, that we should take existing conditions too seriously. The
pessimist never accomplished anything. The teaching profession
is going through the same crisis; it too is planning ways and
means of eliminating the misfit and reducing the number. Those
of you who may be interested, read "Teacher's College Record"
for November, pp. 205, "The Incompetent Teacher," and the
article on "How Many Girls Want to Teach," in the May number of the same publication.
Whatever the outcome of the investigations that are being
made at this time throughout the U. S. and Canada will be, they
have launched the public in general, as well as doctors, hospital
administration and the nurses themselves, out on a train of
thought that cannot but lead to a better realization of their responsibilities, both to the patient and to the nurse.
CHAIRMAN:   Is there any discussion?
(No Discussion)
CHAIRMAN: Our next paper will be given by Miss Mabel
F. Gray, Assistant Professor of Nursing, University of British
Columbia, Vancouver, B. C, on:
"UNIVERSITY COURSES FOR NURSES"
MISS GRAY: The preceding papers have all indicated the
important changes which have taken place in nursing during the
past quarter of a century, and even the layman can readily understand that the education of nurses is to-day a much more complicated procedure than it was when Nursing Schools were first established some sixty or seventy years ago. Nursing, like every
other profession, has gone through various stages as it progressed
gradually from the apprenticeship stage to its present stage
where there is a more or less well-organized body of knowledge
to be imparted to the student-nurse as the foundation upon which
shall be built her practical instruction in the care of the sick.
As the leaders in the nursing world recognized the need for an
enriched training course, they also felt the need of Nurse Instructors with a special preparation for teaching. It was to
meet this need that the University first participated in nursing
education.
In the brief time at our disposal to-day we shall outline the
development of this University contribution. At the outset we
may state that Columbia University led the way, and that nurses
the world over owe a debt of gratitude to Teachers' College of
Columbia University, New York,   for   the   generous   response
89 given some thirty years ago to the request of representatives
from the American Society of Training School Superintendents
to arrange a course and receive that first small group of two graduate nurses who presented themselves for post-graduate study.
The marvelous growth of the seed planted by the nurses who, in
1898, approached Dean Russell with their request, has undoubtedly surpassed their most roseate vision. Canadian nurses are
proud to remember that Canada was the birthplace of the late
Isabel Hampton Robb, of M. Adelaide Nutting, and later of Isabel M. Stewart, whose names are outstanding ones in the development of post-graduate courses for nurses at Teachers' College.
The number of Universities to establish courses in Teaching
or in Hospital Administration did not at first increase at all
rapidly; nurses in general apparently did not recognize the need
for better preparation, and hospitals made no demand that
nurses should have such training. In Public Health Nursing
courses the develpoment was much more rapid. The advances
in the Public Health movement during the early part of this century, with the added impetus given to the movement by the
Great War, quickly made demands upon the nursing profession
which could be met only by some special preparation of nurses
for this field, so courses for graduate nurses in Public Health
Nursing were soon established in several Universities in both the
United States and Canada. These courses have, in recent years,
been developed to meet the needs of nurses wishing to specialize
in the various Child Welfare and Public Health fields. There
is considerable variation in the content of the courses arranged,
in different Universities. Supervised Field Work is generally
included as an essential part of the course; there is considerable
variation as to the time devoted to Field Work as well as to the
time at which it is given. These graduate courses are usually
of one academic year, though in some cases they cover two academic years; of themselves they lead to a Certificate or a
Diploma.
Another step in the development of University courses is
easily understood. Those who were given a taste wanted more—
and we find the graduate nurse continuing her university work
and several Universities generously according to the older graduate nurse University credits for her hospital nursing course, and
awarding her academic standing. This small group has formed
the nucleus, or shall we say the leaven, through which university courses developed.
It is well, I think, to pause here to emphasize the fact that
the development of these graduate courses was in answer to a
definite need, that the development had the support of nurses
90 and of progressive physicians, and also that public-spirited citizens had given very generous assistance—financial and otherwise. We must remember, too, the generous assistance given by
all departments of University which could contribute towards
the better preparation of the nurse.
Though Nursing Schools were graduating nurses in large
numbers, and though a goodly number of graduates were taking
the courses just mentioned, yet the demand for the trained
worker, for the nurse with special preparation for important
executive positions, could not be met. Many graduates appeared
unwilling to accept responsible posts. Something seemed to be
wrong with the Nursing Schools. Many excellent young women
were choosing other professions than that of nursing—professions which appeared to offer greater opportunity for mental
development, and which placed less stress on physical endurance.
Nursing Schools saw that their methods must be altered if they
were to attract young women who would later be able to qualify
for the responsible positions awaiting nurses. Many physicians
were very understanding of our problems and helpful in their
solution. Parents of prospective students, and other members of
the laity, were now giving much greater thought to nursing
needs. University authorities were more fully aware (than they
had been in 1898) of the needs of this new profession and
more ready to accept us — with our still very elastic standards. The University of Minnesota was, I think, the first to
arrange a course for the under-graduate nurse student and in
connection with that University we shall always remember
the name of Doctor Richard Olding Beard. We cannqt
pause to mention the names of all those who have lent the
weight of their influence to help this development, but the
nurses of British Columbia will readily recall what we owe
to Dr. Malcolm MacEachern and. to Dr. H. E. Young, Provincial
Health Officer, in connection with the establishment of the
Nursing Department and the Degree Course in Nursing in our
Provincial University. Many types of University affiliations
were formed by different hospitals, but the one leading to a
University Degree is the most formal one, and it is the one which
will now occupy our attention.
This Five Year, or Degree, Course is now established in a number of Universities on this continent, and Universities in England and in other British Dominions are following the lead. In
China courses have been established, which Miss Goodrich of
Yale after her recent visit to China, states will rapidly surpass
anything on this continent unless we are on the alert. There are
many points of difference in these courses; connected with some
91 Universities, as at Yale, there is a Medical School, and a University Hospital, which is used as a teaching centre for both medical
and nursing students. Other Universities, without hospitals,
must affiliate with one or more General Hospitals to provide the
professional part of the nursing student's training. In this case
there cannot be quite the same elasticity in the plan, and some
consider this situation a very difficult one, but, speaking from
personal experience of such an affiliation between the University of British Columbia and the Vancouver General Hospital, I
can only say that it is working out very satisfactorily. There
are certain other differences, but time does not permit us to
enter into detail.
Chief among the advantages of the Five Year Course in
Nursing are: (1) that it bridges the gap between the age at
which the bright student leaves High School and the age at
which she can be received, with safety to herself and the patient,
into the Hospital Nursing School, and (2) at the same time the
education of the student during this period can be so directed
as to retain her interest in nursing, and, by a study of the basic
sciences, a sound foundation can be laid for her professional
course and for later development. In the University of British
Columbia still another arrangement of courses has been made to
meet the requirements of the under-age student who has matriculated at sixteen. This is a six year, double course, which leads
to the degrees of B.A. and B.A.Sc. (Nursing).
While we, therefore, now have the two types of university
courses—the graduate courses (preparing for special fields), and
the undergraduate or degree course—the latter really includes
the first, as the fifth or final year is spent in preparation for
one of the special fields. The graduate courses, naturally, still
attract the larger number of students—but, to me, the five-year
course appears to be the ideal. With the knowledge older nurses,
at least, have of the defects in our past system of training, we
must surely agree that the policy 'is sound which lays the foundation for the professional course by the two pre-clinical academic years, and which also lays the foundation for other forms
of post-graduate study to meet the requirements of our profession. To the five year course, we look for the leaders in nursing
in the next decade.
To sum up the situation—we may say that there has been
during the past twenty years a gradual, but steady, improvement
in nursing standards, and that for a selected group there has
been an even more intensive preparation secured through our
university courses. It may be asked whether the needs of our
profession justify the endeavors to raise our nursing standards.
92 In the United States and in Canada, Grading Committees and
Survey Committees are at work, and are presenting their findings on just such questions. Sufficient evidence, has already
been presented to make us feel that our developments have been
in the right direction, but that our efforts should be redoubled.
While the nurse must lose none of her deftness of touch, none
of her care in carrying out the physician's directions, none of
her devotion to duty—yet much more is expected of her, and it
is only as she has been trained to "think" as well as to "do"
that she can measure up to the expectation and demands of the
present-day physician and patient. Knowledge fundamental to
nursing must be organized and presented to students in the best
way; our methods of teaching nursing subjects and practical
procedures must be critically analyzed. Much original thinking
must be done. We shall look for leadership to the graduates of
university nursing eourses—when by practical experience they
have gained the necessary background—and in nursing, as well
as in every other profession or calling, the well-trained worker
will undoubtedly demonstrate the value of a sound education.
CHAIRMAN: Is there any discussion on this paper?
(No Discussion)
CHAIRMAN: We shall now have a discussion to be opened
by Miss Grace M. Fairley, R.N., Superintendent of Nurses, Vancouver General Hospital, Vancouver, B. C, on:
"DIETETIC COURSES FOR NURSES"
MISS FAIRLEY: Madam Chairman and members, I have
no paper to offer. As a matter of fact, when I gave some thought
to the question of dietetic courses for nurses I took it for granted
that I would be speaking to the dietetic section and hoped that
there would be some dietitians present. I feel that there is a great
need for a closer contact between the nursing section and the dietitian teaching group in this day when dietetics play such a tremendous part in the treatment of disease. The subject of dietetic
courses for the student is tremendously important and the question of co-operation between the dietetic department and the
nursing department is of vital importance. The course for
nurses is important from the point of view of the patient's meals
because after all she is serving a meal in which she has had
no part in the preparation, and if there is not a real and sincere
co-operation between these two departments the nurse may not
be very much interested in; the serving of that meal. It may be
something has been overlooked, or the food has been burnt and
the nurse waives the responsibility if she has not been taught
that the diet of the patient is of great importance to the hospital.
93 Then there is the purely educational point. In the treatment of
disease it is just as vital that the nurse should know the content
of the diet for any special disease such as diabetes, etc., as that
she know the 'content of a prescription. And after all, in the final
analysis is it not the nurse who receives the complaint from the
doctor if the diet has not been well prepared or if it is not correct? It is therefore tremendously important and it behooves us,
as nurse educators to encourage the fullest co-operation between
the dietitians and the nursing staff. I think I will not touch on
the content of the course; it is practically laid down for the use
of the majority of hospitals in the preliminary course. Just
here let me say to those who have not a well-equipped dietetic
laboratory, that the Provincial Government, through the Department of Education, is very willing at the present time to offer
the use of household science classrooms for this preliminary
course; unfortunately the classrooms cannot be used during the
day but they can be used from 4 to 6 o'clock in, the afternoon.
It can either be arranged to have the dietitians from the hospital
take the classes at the school or to have the teaching staff of the
Board of Education give this preliminary course; the decision
has been left with the Department of Education as to which
method shall be used. It is of vital importance that the teacher
should be invited to visit the hospital and see something of the
background in which the nurse student is receiving her preparation, and again I would like to urge that the dietitian be considered in every way both in the publications of the hospital and
in all hospital literature as a member of the teaching staff. Also
in the appointment of. a dietitian, if she is to be single-handed
she should have teaching ability, but if connected with a larger
hospital, at least one of the dietitians should be capable of teaching. In some hospitals the dietitian comes directly under the
Superintendent's department, and in others under the Superintendent of Nurses. It does not matter very much but there is.
one thing to say, and that is when the dietitian comes under the
department of the Superintendent of Nurses, probably there is
not the same tendency to resent criticism as if the Superintendent of Nurses has to go to the Superintendent to get any adjustment.
Then many of the hospitals are guilty of having the student
nurses do the work that can be done by maids or cleaners, and
also it is the custom for them to use the student nurses for repetitive kitchen work. Many of the hospitals are guilty of this
practice.
Probably the latest development in hospitals in connection
with the dietary department is the out-door clinics which are
94 being universally developed and if they are not developed, should
be. Many of the patients who are put in hospitals for diabetes
could be given the proper care and instruction in an out-door
clinic and left in their homes. These clinics offer great assistance to ex-patients who are not capable of looking after themselves, but they must be organized; and they form a tremendously vital part in the education of the student nurses. The
student nurse should be present at these conferences because
it gives her an idea of the background from which the patient,
who is not a resident patient, comes; in these days when we
hear so much about preventive work I think we should keep
that in mind. -There are many patients who can carry out
instructions much more satisfactorily and more economically in
their own homes. Thinking I would be speaking to a group of
dietitians, I was going to express my appreciation for the opportunity of bringing up this point, but seeing they are not present
I would like to say to the hospital authorities that I think we
should have a greater contact with the Deans of the Household
Scienee Schools and Colleges. They may argue that the hospital
dietitian is merely one department and they could not give too
much attention to it, but it is tremendously important to the
majority of hospitals that the Household Science Colleges and
Schools should take some time in studying the needs of the dietitian in the hospitals, and there is a need for a dietitian to know
something of the nursing treatment. A dietitian who is working
out special diets who does not understand the regulation of the
dose of insulin or how to make a urine analysis, is under a tremendous handicap. I do think this a matter that should be discussed with the Deans of these schools. Our nursing service has
been run too much as a unit without sufficiently conferring with
those women who are preparing students for a tremendously
important part. Second only to the surgical operation in a surgical case is the dietary treatment of disease to-day.
CHAIRMAN: May I extend your thanks to the very able
speakers who have taken part in this morning's proceedings?
Upon motion the meeting adjourned.    12 Noon.
95
i.— WEDNESDAY AFTERNOON SESSION
August 20, 1930
PRESIDING: Mr. J. H. McVety.
CHAIRMAN: Miss Ethel C Pipes.
The Afternoon Session was called to order by the Presiding
Officer, Mr. J. H. McVety, who called upon Miss Ethel C Pipes,
Chief Dietitian, Vancouver General Hospital and Sectional Chairman of Western Hospital Dietetics Association, to conduct the
Dietetic Section of the Convention. Miss Pipes explained that
the speakers for the afternoon had been invited, to address informally a small group of hospital dietitians, not a General Session of the Joint Associations. At the same time the Chairman
expressed pleasure at the interest displayed by the large audience.
The first speaker of the Afternoon Session was H. W. Hill,
M.D., D.P.H., LL.D., L.M.CG, Director of Laboratories, Vancouver General Hospital, and Professor of Nursing and Health
and of Bacteriology, University of British Columbia, on the subject of:.
"NUTRITION WITH REFERENCE TO THE PHILOSOPHY
OF LIFE"
Dr. Hill's-address was well received; reference in it to interesting experiments now being carried on in the feeding of
young children by Doctor Davis of Chicago, and details of this
experiment given by Dr. Koehne in answer to a question from
Dr. Hill, proved very interesting.
CHAIRMAN: I shall now take great pleasure in calling on
Dr. Martha Koehne, University of Tennessee, Vice-President
American Dietetic Association. Miss Koehne obtained her Doctor's degree at Yale some years ago and is now going to the
University of Michigan to do a very nice piece of research work.
Dr. Koehne's subject for this afternoon's discussion is:
"SOME OF THE NEWER PHASES OF NUTRITION"
Dr. Koehne presented in a most interesting way some of the
newer phases of nutrition, dealing especiaUy with "Vitamines B
and D and with the role of copper in the assimilation of iron in
Nutritional Anaemia. Varied and interesting experiments were
described, and the practical application outlined.
(NOTE—It is much regretted that the two preceding addresses are not available for publication.)
CHAIRMAN: I shall now ask Mr. Harry R. Beard, M.Sc,
96 Director of Scientific Research, New England Fish Company,
Vancouver, B. C, to speak to us on the subject of:-
"PRESERVATION OF FRESH FOODS BY FREEZING"
MR. BEARD: Much is now being said and written about
rapid frozen foods. Trade and technical journals covering foods,
even women's magazines, and newspapers now frequently contain articles on this subject. All of us eat food; most of us show
a keen interest, not only in what foods we eat, but in' their quality and tastiness, and some of us are interested in' the more technical aspects of foods; consequently, this new development which
may profoundly affect our food supply is'of m'ore or less interest
to all.
In discussing developments in this field one must,, confine
his remarks largely to fish, since the fisheries industry is pioneering in this work.
Fish is one of the most perishable of foodstuffs. Unlike
meat, in which a certain amount of aging is considered' desirable, fish is best when very fresh. It was early recOghized that
freshness could best be preserved in fish by keeping1 them cold.
At first the fish were kept separate from the ice, but later,
(about 1845) ice was mixed with the fish. This is'still the
most widely used procedure for keeping fish fresh.' From two
to three weeks from the time they are caught, however, is as
long as it is possible to preserve in good condition even such
good keeping fish as halibut and! salmon, when ice is used as a
preservative. It was necessary, however, to be able to' keep the
fish longer than this, for most fish are obtainable only at certain times of the year and then the catch is apt to fluctuate
greatly from day to day. The urgent need was for'some method
of preserving the surplus catch in approximately-:its. original
condition for long periods of time so as to even out distribution over the year and to widen markets by being able to ship
fish farther. Artificial freezing and storage at temperatures
below freezing was developed to meet this need. The first fish
were frozen artificially in about 1861. Since then, this method
of preserving fish has developed rapidly, largely because, out
of all methods of keeping fish for long periods of time, frozen
fish alone retain essentially their original characteristics.
Practically all fish frozen before the development of quick
freezing processes were frozen by the so-called "sharp" freezing method. Even to-day, most frozen fish are "sharp" frozen.
In this process small fish are usually packed into galvanized
pans to as to form a block when frozen, and large fish are frozen
singly.   "Sharp" freezers are large insulated rooms containing
97 tiers of pipes laid horizontally so as to form shelves. These
pipes are refrigerated with very cold brine or with ammonia.
They take up heat from objects resting upon them or upon the
sheets of galvanized iron that are usually laid on the pipes.
When freezing is completed the pans of fish, or the individual
fish, are removed from the freezer and taken to a low temperature room for glazing. Here the blocks of fish are removed by
warming the- pans slightly with water; then the blocks or the
individual fish are given a short dip in cold water. The reserve
refrigeration in the fish and the cold air in the room combined
cause a film of ice to form over the surface of the fish. This
procedure is repeated until a thick coating of ice is formed; then
the fish are sent to the cold storage rooms. These rooms are
usually kept at from 15 degrees to zero Fahrenheit. In
these rooms there is considerable transfer of ice from the fish
to the cold pipes which cool the room. The ice glaze is put
on the fish so that it will evaporate rather than water from the
fish themselves. Another purpose of the glaze is to protect the
fish from oxidation changes due to contact with the air. Shipment to distributing warehouses is made in boxes in refrigerated cars or boats, the fish being kept frozen at all times.
"Sharp" frozen fish are the so-called slow frozen fish, about
which more will be said later when discussing rapid freezing.
It is sufficient for the present to say that much "sharp" frozen
fish in the past .has been quite different from fresh fish when
consumed. In many cases this undoubtedly was due to the quality of the fish-being poor when they were frozen. In other cases,
however, the quality was perfect when frozen, and some other
explanation had to be found. This led to research into the reason
for the undesirable changes that took place in the fish.
In 1916, three German investigators, Plank, Ehrenbaum and
Reuter, published the results of studies they had made on the
effects of different freezing rates on fish. They found that the
more quickly the flesh was frozen the smaller the ice crystals
that were formed in the flesh. This focused attention upon rapid
freezing, and this formation of small ice crystals during rapid
freezing has been stressed by numerous investigators since that
time, until now most people believe that frozen fish must be
rapidly frozen to be of high quality. Certain investigators who
are carrying on research in freezing fish doubt, however, that
rapid freezing is as important as has been claimed. Our laboratory, too, is wondering about this problem and we are carrying
on extensive studies this year in an endeavor to answer this
question to our own satisfaction. Until we know definitely in
regard to this matter we will assume rapid freezing to be an
98 important factor. One thing we know for certain, and that is,
that rapidly frozen fish deteriorate greatly if conditions of storage are not right, and because of this fact we are inclined to
believe that the conditions of storage have been responsible for
a considerable part of the objections that have been brought forward in the past to '' sharp'' frozen fish.
The theory in regard to rapid freezing that has developed
based upon the work of Plank, Erhenbaum and Reuter mentioned
above, is that during slow freezing large crystals of ice are
formed, which, in the process of formation, disrupt the cellular
structure of the fish, freeing juices which are lost when the fish
is thawed. This theory furnishes an explanation for the loss
of juices from thawed fish and the lack of juiciness in the product when cooked. Since small crystals are formed in rapid
freezing it has been assumed that the cellular structure is not
seriously affected, hence the resultant product is approximately
the same as fresh fish.
Experience has not fully substantiated this theory. Certain
kinds of fish, even when very rapidly frozen — fish that were
almost perfect when thawed and eaten right after being frozen
—take on after a few weeks' storage, even under excellent storage conditions, many of the properties that are attributed to
slowly frozen fish.
Although there are some doubts about the real value of
rapid freezing and we must wait for the answer to certain questions before we can definitely decide; yet, rapid freezing is a
distinct step forward. Rapid freezing, combined with improved
methods of treating, storing, shipping and merchandising is giving the consumer far better fish than before these developments
took place. These different points will be taken up as soon as
the discussion of what constitutes rapid freezing and how it is
carried out is completed.
True rapid freezing is only obtained with slices and fillets
of fish, these being frozen in a number of ways in from twenty
to sixty minutes. Large whole fish, being so much thicker naturally freeze much slower. By the newer rapid freezing processes a ten-pound salmon freezes in about three hours instead
of in about twelve hours by the older "sharp" freezing method.
With a forty-pound halibut the time is about six hours instead
of about twenty-four hours.
There are a number of different procedures followed in rapid
freezing. One is to place the object to be frozen on a metal
plate, the bottom side of which is in contact with rapidly moving
cold brine.    Heat passes out of the object through the metal
99 wherever it touches the object, and to the cold air of the room
which surrounds the rest of the object. For thin pieces of fish,
such.as fillets and slices, this procedure gives quite rapid freezing, with brine temperatures of minus ten degrees Fahrenheit
or lower.  .
Another procedure is to place the object in a metal container
with hollow walls through which cold brine is circulated; or the
container is immersed in rapidly moving brine.
Still another method is the so-called brine freezing process
which consists in immersing the object directly, without any protective coating, in rapidly moving refrigerated brine, usually
a saturated sodium chloride solution which has a freezing point
considerably lower than the object.
The most widely discussed process, however, is Birdseye's
— controlled by the General Foods Company. In this process
the individual pieces or packages of fillets are carried between
two moving belts, the opposite sides of which are showered with
cold brine. The upper belt is heavily weighted and movable
up and down. The lower belt runs on fixed rollers. In this
way, objects passing through are firmly pressed between the two
belts, thus making good contact with them. The movement of
the belts carries the objects from one end of the unit to the
other, during which time freezing takes place. This equipment
is designed so that no brine comes in contact with the objects
being frozen.
The introduction of rapid freezing processes in the fisheries
industry has accelerated development of other improvements
which are now a part of the industry and are so closely allied
with rapid freezing that they must also be considered. The reason
why these improvements were developed can best be understood
by first briefly reviewing some more of the difficulties that
have faced the industry.
The fisheries industry has always suffered from inadequate
merchandising, caused chiefly by the difficulty of handling fresh
fish. Grocery stores cannot keep loose fish in their ice boxes,
and to have iced fish and a cutting block is out of the question
in most stores. For similar reasons butcher shops except in a
few instances, and these usually only on Friday, do not find
it advantageous to handle fish. This leaves only the fish markets, which, because of small demand and frequent periods when
fresh fish are unavailable, are few and far between. This small
demand usually is due to the lack of excellent quality fish and
to the unattractive manner in which fish are frequently displayed.
100 One important advance in the marketing and merchandising of fish took place a number of years ago with the introduction of iced fillets. Large quantities of haddock on the East
Coast are now handled in this way. The fillets are usually washed
in brine, wrapped in parchment paper, chilled thoroughly in a
cold room and packed in tin boxes holding about thirty pounds
of fillets. These tins are packed in wooden boxes with large
quantities of ice surrounding them. Shipment is made by express. In this method, the waste parts of the fish are left at
the producing centres where they can be profitably utilized.
Here, for the first time, was fresh fish in fillet form, wrapped
in parchment paper which does not fall to pieces when wet and
upon which is printed the dealer's trade-mark, name and usually recipes. Such a product is relatively easy to; handle in the
store and in the home. It has given better fish to the public
because being trade-marked only the best of the catch is used,
and the method of shipment is a distinct improvement over older
methods.
Important as this development is, it still does not meet all
the needs. The fillets are only iced, hence the time which tFey
can be kept and the distance to which they can be shipped are
limited. This procedure, too, only permits fish to be marketed
when they are available. The solution to these difficulties has
•been properly prepared consumer packages of rapidly frozen fillets. Such a product as this, properly stored, shipped and handled by the retailer, enables the consumer to buy anywhere and
at any time the very best fish, free from waste and ready for
the pan. Being in a sanitary wrapper or package, bearing the
trade-mark of a reputable producer, the product can be always
depended upon.
It will be of interest to outline the procedure followed in
producing and distributing frozen fillets and to point out some
of the difficulties encountered.
One of the largest producers before freezing its fillets brines
them for a short period of time in a solution of sodium chloride,
or common salt, to which other harmless substances have been
added. They claim their reason for doing this is to make certain adjustments in the flesh which keeps the fillets from becoming tough and losing soluble extractives when they are
thawed after having been in cold storage for several months.
This brining also adds a harmles substance which prevents white
fillets from turning slightly yellow after long storage. There
is no doubt but that this treatment is of great help.   One other
101 large producer brines fillets in a plain sodium chloride solution,
which salt alone helps prevent drip and toughness if properly
used.
Here on the Pacific Coast, with our salmon we have still
other troubles. Salmon is a fat fish and the oil in the flesh oxidizes during long storage, giving a disagreeable flavor and
appearance to the product; also the red color fades, unless special
precauti'ons are taken to prevent these different changes. We
are meeting with considerable success in preventing these undesirable changes in the salmon fillets we are producing; also
in preventing changes similar to those previously mentioned in
both our salmon and halibut fillets.
Most fillets are frozen singly, then sealed in waxed parchment paper bearing the manufacturer's trade-mark, or they are
wrapped in moisture-proof cellophane. One company, however,
wraps its fillets in moisture-proof cellophane, then packs the
wrapped fillets compactly into a carton, freezing the whole into
a block. The moisture-proof cellophane keeps the fillets from
drying out in storage and also permits the individual pieces to
be easily separated while in the frozen condition.
Corrugated cartons holding 10 to 15 pounds of fillets are
used extensively for singly frozen fillets. These cartons have
special water-vapor resisting liners and all edges of the carton
are taped to prevent the fillets from drying out in storage. These
cartons also prevent odors from leaving or entering the cartons.
Fillets packed in this manner can be stored with butter or any
other food product without the latter acquiring any fishy flavor.
These packaged goods are usually stored at about zero degrees Fahrenheit or lower, the temperature being kept very constant. They are shipped to distributing cold storage warehouses
in refrigerated cars. One company uses a fleet of about forty
special mechanical refrigerator cars in which the temperature
is automatically maintained at about 15 degrees Fahrenheit for
days at a time, enabling them to ship frozen fillets at all times
of the year anywhere in the United States or Canada.
In distributing the frozen fillets, refrigerator Itrucks are
used in some localities and in some of the dealers' stores there
are low temperature electric refrigerators which keep the fillets
frozen until delivered to the consumer. This is the ideal way
of handling this product, since it assures the purchaser fish of
a quality heretofore only obtainable at points where fresh fish
is produced. Where a low temperature refrigerator is not available the dealer can keep the frozen fillets in his ordinary ice
box. They will slowly thaw out, but will keep in excellent condition for several days.
102 To produce frozen fillets in May in Boston and sell them
in December in Los Angeles demands lots of facilities and doubtless more care than is now given to any other food product. The
failure of any step from the time the fish are caught until the
fillets are delivered to the consumer means disaster.
Considerable quantities of rapid frozen whole Pacific Coast
halibut and salmon are now being produced in Canada and the
United States. The smaller fish of the Great Lakes are also
being rapidly frozen. Then, there are rapid frozen oysters,
shrimps, scallops and other sea foods on the market.
The meat packers are showing a great interest in packaged
rapidly frozen, consumer cuts of meat and some of them are beginning to produce these products. Many people are of the
opinion that it is only a; matter of time until most meat is sold
in this manner. It is claimed that important economies can be
effected by having the meat cut at the large producing centres
where the waste parts can be better utilized. It is also claimed
that better distribution of the different cuts toi the various
markets can be made. Extensive tests will have to be made before it is known whether or not these claims hold good. It is
certain that many technical difficulties will arise which will
have to be solved before real progress is made. The problems
probably are not quite as simple as claimed by some of the quick
freezing enthusiasts.
Extensive research is being carried out on the rapid freezing
of other food products, particularly such seasonal articles as
berries, fruits, and vegetables. Studies are also being made in
the marketing of these products, in the frozen state, in consumer
packages. Considerable progress is being made, too. The difficulties, however, are many, but on the other hand the possibilities
are very great.
It is very interesting to look forward to the possibility of
being able to have most of one's favorite foods at any time in
approximately the condition they would be if freshly produced,
and to be able to distribute them almost anywhere in this condition.
The realization of such hopes as these should mean much
to the dietitian. Prime quality fresh foods are of great importance in the diet. There can be no question about the nutritive
value of such foods; and, having the appetizing qualities of
fresh foods they should appeal to all. Cold, combined with proper
packaging, offers the greatest possibilities of all preservatives
for maintaining the essential biological qualities of foods without
loss or impaired value.
103 Let us again consider fish and see what the developments in
the handling of this important food product mean to the dietitian. Sea, fish and sea foods in general, because of their high
mineral content, included in which is iodine, the high biological
value of their protein, their vitamins, and their ease of digestion recommend themselves for invalids. Hospitals, particularly •
in the interior of the country, have found it difficult, and in
many cases impossible, to obtain fresh sea foods of good enough
quality to make much use of them. They have learned that
their patients either will not eat such foods or they show no
enthusiasm for them. Now, however, certain packaged frozen
sea foods are obtainable which are the approximate equals of
the freshest products obtainable at the sea coast.
It should be emphasized that these frozen products are superior to fresh ones that have been only iced and shipped inland.
The temperature of melting ice only slows down detrimental
changes ;• proper freezing, packaging and low temperatures practically stop deterioration. The variety of products such as these,
and the localities in which they can be procured, are constantly
expanding, so that in time a large variety should always be
available.
With the coming of other frozen food products some day
it probably will pay hospitals and other institutions to have a
special low temperature storage cabinet in which they can keep
such foods, withdrawing from day to day the amounts and varieties needed.
It looks as if the fisheries industry, which for ages has been
very backward technically, is pioneering developments in the
distribution Of foods that probably will be of great importance.
CHAIRMAN: Our next speaker is one of our presiding
officers, Mr. G. W. Olson, Superintendent California Hospital,
Los Angeles, California, who will discuss the very important
question:
"FOOD COSTS AND FOOD BUYING"
MR. OLSON: My talk this afternoon will be a plain and
simple business talk on "Food Costs and Food Buying." I will
first deal with food costs. This will not be done in any scientific way but from the standpoint of a plain business man. Food
costs are a very considerable portion of the total costs of maintaining your hospital. Just what proportion it amounts to I
will mention.later. I have made no broad study of this question
but have only followed out my own experience in our own institution which. I think is fairly typical of a great majority of
hospitals.   In these hospitals, when we notice the mounting costs
104 of our budget for food we should ask the question, "How are
we buying it, are we buying properly and are we buying the
proper amount of food of each particular kind or are we overfeeding our patients with certain types of food and under-feeding them with others?" I was puzzled about these questions until
some time ago, I believe it was in the April number of Hospital
Management there was an article by Kate Daum, Ph.D., of the
University of Iowa, in which there was a standard set up by
which you can analyse your food bill and see what it amounts
to in dollars. Dr. Daum sets up a standard of a general menu
for the hospital.
Taking patients, employees and all workers as a whole, 25
to 31 per cent, of your food bill should go for protein foods, 25
per cent, for milk and dairy products, 25 per cent, for fruits and
vegetables, 10 per cent, for bread and cereals, 9 per cent, or
less for sugar, coffee, tea, etc. I took this standard and analyzed our food purchases in our hospital. We have an institution of 307 beds, with a daily average last year of 265 throughout the year, varying from 235 to 300 and a household which
increases that number to about 735. I finally came very close
in our purchases to Dr. Daum's standard. In some things we
were below and in some things we were over. We used considerably more in fruits and vegetables, but our pastry, flour,
cereals, etc., were below, but upon re-check, we altered our purchases to some extent and are now closer to her standard, which
I think is a good one. I will not deal with any statistical tables
of food costs but will simply and briefly tell you what we have
found out to be the average daily cost of food per patient as
well as per person. With a household of 735, the daily average
or cost of raw food per day per patient was $1.20 and per person it was 41.4 cents, that is for the raw food without the cost
of preparation. With the labor cost this amounted to 43.6 cents,
or for the entire household of 735 it amounted to 15 cents per
day for the cost of preparation and serving. The cost of the
expense connected with the preparation, serving, maintaining
and staffing the kitchen, utensils, etc., amounted to 7 cents per
day per patient or 2.42 cents when we consider all persons
served. The total cost of dietary department after allowing
credit for meals served, because we have a guest room in which
meals are served and paid for, including the purchase of food,
labor, preparation, service, dishes and utensils we figure the
amount to be $1.65 per day per patient, or 57 cents per day per
person supported, but the patient has to pay the cost. I have
made no comparisons particularly except with some of our local
hospitals and I think they run a little below this, but some of
105 them run above, so I believe this is fairly reasonable and that
there is no occasion for us in our institution to attempt to bring
that cost down. I do not believe we are extravagant or penurious, but that We have a fair average at $1.65 per day per patient.
As to the cost of the dietary department, that includes dieti-.
tian salaries and salaries of the kitchen workers, but does not
include utility, such as gas or water or depreciation on equipment.
I think in most institutions if you give proper attention to
your dietary department you will find it is responsible for most
of the compliments. The dietary department is one department
through which you can advertise your hospital more and more
effectively than through any other department. The dietary
department is a very, very important one. So much for the costs.
You will remember that was $1.65 per day per patient but 57
cents per day for the total number of persons in the hospital.
Now we come to the question of food buying. The most
important question is to decide who shall do the buying. We
have settled that and I frankly believe the dietitian should be
charged with the responsibility of buying the food. In cases
where extensive contracts covering a long period of time are
involved, naturally she should confer with the executive business
head of the institution. She will not give a standing order to
the produce dealer or to the wholesale grocer without consulting the Superintendent, but she will decide after sampling and
testing and investigating the quality of food offered, what and
where to buy. There are some who will hesitate to turn over
to the dietitian that responsibility, and there may be good reasons. Let us remember the dietitian spends approximately 20
per cent, of the total amount expended for the maintenance of
the hospital. In the case of the institution of which I am speaking the anual food bill is $118,000 and that is more than all
of the supplies purchased by all of the other departments —
administration, including stamps and stationery; housekeeping,
including all linens; laundry; engineering and utility, including
all your fuel, gas, electricity, etc. Every department I have
listed here and still that amounts to only $3,000 more than the
dietitian spends. The dietitian spends $118,000 whereas these
other departments which include your medical and drug supplies, etc., spend $121,000. Do you wonder then that many
hospital executives hesitate to allow their dietitian to spend that
amount of money? I want to impress upon the dietitians the
fact that there is a tremendous responsibility involved in the
authorization for you to buy all of the food supplies for your
hospital and you should carefully prepare   yourself   for   that
106 responsibility before you undertake it. Nevertheless, I recommend that it should be done, and I hope that the dietitians will
more and more measure up to the responsibility that is placed
upon them.
The next point I wish to make is — how to buy. Buy only
the things that you absolutely need. We are too busy in hospitals to help manufacturers to introduce new products. Let us
stick to the standard things and buy those things that are in
demand. I again repeat, buy only the goods that are staple and
that you find you can use economically and with satisfaction
to your patients and to your household. Buy when you need
it and not before. That applies to almost everything except
certain lines of preserved fruits. I would advise you to be conservative in your buying and have just enough on hand for the
next month or so but not any longer.
The next point is where to buy. We in the hospital business are importuned every day in the week by men coming across
the continent to sell us goods we can buy next door, and all
kinds of pressure is brought to try to make us buy from New
York the things we can get at home. We are buying everything
we can possibly buy at home from the most reputable merchants
and concerns in our own community because that is one way
you can build up goodwill for your institution. If you are in
need of funds to clear up the budget deficit you must go to your
own community and if you have not built up goodwill there by
giving them your patronage you have no right to ask for their
help. It is our policy to deal with the reputable houses in our
community. Buy as much as you can in your own community
and build up good will.
CHAIRMAN:   Is there any discussion?
(No Discussion)
CHAIRMAN: We now come to the final discussion of this
afternoon's session and I shall call upon Mr. J. G. Jervis, B.V.Sc,
Lecturer of Veterinary Science, University of British Columbia,
Vancouver, B. C, who will speak on the subject of:
"THE CANADIAN MEAT INSPECTION SYSTEM"
MR. JERVIS: The necessity for a careful sanitary control of
our food is growing greater year by year. This is especially necessary in the case of animal food products, in particular meat and
milk, which are most apt to carry infection and which decompose
readily. The necessity for this inspection is accentuated by the
fact that the producer and the consumer are often separated by
great distances and further, there are several middlemen be-
107 tween the two. The ignorance or greed of the middleman or
the producer may force upon the consumer meat that is injurious or that is considerably below value. The danger does not
consist alone in eating infected or decayed animal products, the
mere handling of the flesh of animals having anthrax or glanders
may be sufficient to transmit infection to the butcher or housewife who may injure themselves in cutting the meat.
The main objects of meat inspection are the protection of
health from animal diseases and parasites communicable to man
and the sanitary destruction of all condemned carcasses and
organs. An efficient meat inspection system is not only of advantage to man but is a means of detecting and preventing
diseases among the animals themselves. A sharp outlook at the
slaughter house will discover the first appearances of rinderpest,
foot-and-mouth disease, Texas fever, or other epizootic, which
may then be quickly traced to its origin and nipped in the bud.
In Canada, this inspection was inaugurated in 1907, when
the Meat and Canned Foods Act came into force. This Act was
passed partially on account of public sentiment, which was
aroused through the Chicago Packing House exposures, but
chiefly to preserve our valuable export trade in bacon and similar products. The Meat and Canned Foods Act applies only to
those abattoirs that are in the export trade, though in the meaning of the Act, export is the shipment of meat from one province
to another, as well as to a foreign country. As previous to this
the Public Health Act of 1872 gave the 'provinces control over
their own health questions, the Dominion Government has no
control over plants in the local trade.
At the present time there are some forty-nine establishments
under permanent Federal inspection, and some eleven under temporary inspection. The inspector in charge of each plant is a
veterinarian and he has one or more assistant veterinarians and
laymen under him. The inspector in charge is responsible to
the Veterinary Director General at Ottawa for the maintenance
of the inspection of his plant. All meat and meat food products
that are passed as fit for human consumption are stamped, or
the containers are marked with the inspection legend. This
legend consists of a crown surrounded by the words "Canada
Approved," together with the number of the establishment. Although inspection is only given to plants in the export trade,
nevertheless all animals slaughtered are examined whether they
are intended for export or not.
It is a duty the province and municipality owe to their citizens to establish a system of meat inspection that will afford
adequate protection against diseased and unwholesome meats.
108 All meat sold locally, which has not passed federal inspection,
should come under the requirements of an efficient local inspection system. In this connection let me quote the Third Annual
Report of the Commission of Conservation, Committee of Public
Health for 1912:
"A question which should engage the immediate attention
of municipal authorities and provincial legislative bodies is that
of the food supply, and more particularly of good, wholesome
meat. This is all the more urgent as, under the present excellent service of the Veterinary Director General, a rigid selection
in respect to our export meat trade is made, both of animals
intended for slaughter and of the carcasses at the time of slaughter. The bulk of the meat so slaughtered is sold in foreign ports,
but little being disposed of for home consumption. We thus
find ourselves in Canada in the anomalous position of enforcing
laws which, when applied to their ultimate extent, militate
against the highest interest of our own people insofar as they
relate to a good wholesome meat supply.
"If it is in the interest of the foreign consumer that the
present Dominion System of Meat Inspection should be carried
on, how much more so should a similar system be carried on
throughout the length and breadth of Canada in the interest of
7,000,000 Canadians? If the former method is right and sanitary,
then our provincial laws, in so far as they relate to meat for
home consumption, are wrong.
"What is good for the British consumer is not too good for
the Canadian."
In some cities meat inspection is enforced by laymen, such
as butchers, cattlemen, or even men further disconnected with
the practical side of the work, and they are seriously handicapped because of their inability to recognize lesions, which would
at once appeal to one trained in the anatomy and pathology of
domestic animals. Our system of inspection, which I think is
equal to any, consists of an examination of all animals, both before and during slaughter. The post-mortem is especially thorough. One or more veterinarians ard on the killing floor while
slaughtering is going on. Each and every animal receives a
careful and conscientious autopsy. Any animal found diseased
is marked with a "Held" tag, a record of all lesions found is
made, the carcass and viscera are then removed to the detention
room, where a final examination is made at the inspector's
leisure. If considered fit for food the diseased portions are
removed and condemned and the rest of the carcass passed. If
an animal is found to be grossly affected, it is at once tagged,
condemned and removed to the condemned room until it is con-
109 venient for it to be tanked, along with sweepings from the floor,
offal, and other inedible portions. As a temperature of 360 degrees F. is maintained for about eight hours, the reduction is
very complete. The tanking is under the direct supervision of
an inspector and the method employed eliminates any possibility
of condemned carcasses being used for human consumption.
There are some sixty or seventy diseases, or conditions, for which
we condemn carcasses or portions, the most common being tuberculosis, lump jaw or actimomyeosis, pyaemia, septicemia, parasites of various kinds, hog cholera, and swine plague, skin diseases, sexual odor, tumors, bruises, abscesses, emaciation, immaturity in calves, etc.
Meat may occasionally be injurious to health from a variety
of miscellaneous causes, thus, an animal that has died of arsenic
or other poisonous substance may contain sufficient of that
poison in the tissues to affect the person who eats part of the
flesh.
In the year ending March 31st, 1930, out of some 4,100,000
carcasses examined, some 25,000 were totally condemned, a percentage of over one-half of one per cent. In addition to this,
some 750,000 portions were condemned. Cattle had the worst
record, with a percentage of 1.49%, and sheep the best with
.23% Next to immaturity in calves, tuberculosis is the cause
of most condemnation in cattle; it also leads the list in hogs. This
disease is seldom or never found in sheep. Nearly one million
pounds of meat were condemned on re-inspection.
With the growing scarcity of meat it becomes more important that ever that the meat supply should be conserved and that
no wholesome food is wasted. The first aim is to protect the
health of the consumer; there is no disposition on the part of the
inspector to pass for food any meat that is unwholesome or even
of doubtful wholesomeness; but it would be an economic wrong
to destroy on purely sentimental grounds meat which is known
scientifically to be perfectly wholesome. It should be understood that we do not pass diseased meat; we only pass under certain circumstances the sound and wholesome meat of a slightly
diseased animal, after removing and condemning the affected
portion. The argument that all affected animals, even the
slightly diseased ones, should be totally condemned and destroyed, if carried to the extreme, would result in the condemnation of nearly every animal and the abolition of meat as a food.
The mere fact that meat has passed inspection does not prevent it from subsequently becoming contaminated with the germs
that cause meat food poisoning.   This particular group of germs
110 deposited upon a roast, steak or carcass will grow readily and
rapidly throughout the mass, especially if kept warm. It is easy
to see how meat may thus become infected through the contamination of dirty hands, butcher's implements, soiled meat
blocks, flies, careless handling in the home, etc. Emergency
slaughter is very dangerous and four-fifths of the epidemics of
meat food poisoning in the last ten years have been caused by
this class of meat. An unscrupulous farmer or dealer will not
hesitate to bleed and dress an animal even if it isi in the last
throes of death. In fact, there are numerous cases on record
where dead animals have been dressed and sold as first class
meat.
So long as butchers are permitted to slaughter animals at
any hour of the day or night, in any barn or cellar or filthy
slaughter house, it is absolutely impossible to exercise a proper
control over meat and meat food products. I consider it the
bounden duty of every municipality to pass a by-law permitting
only meat that has passed a rigid veterinary examination to be
offered for sale within its limits. Such a by-law would necessitate the employment of one or more veterinary inspectors and
the erecting and maintaining of a modern municipal abattoir,
where, upon payment of a small fee, the small, independent
butcher could slaughter his animals. This would permit the
careful inspection of all animals under sanitary conditions, at
the same time conserving the inedible products obtained from
tanking condemned carcasses and portions. If we do not provide some establishment where the small man can slaughter, we
shall place ourselves in the hands of the large packers. You
well know what mercy the public could expect from them. The
results, to say the least, would be disastrous.
Country killed meats may be permitted to be brought in
providing the tongue, lungs, heart and liver are held by their
natural attachments. This will permit of an examination to be
made when it arrives at the market. It should not be allowed
to be offered for sale until an inspector has given it a careful
examination. Ordinary market inspection is worse than useless
in that it gives people a false sense of security. ! It is very easy
for an unscrupulous dealer to remove evidence of disease to such
an extent that an expert would have, great difficulty in detecting it. I have often heard butchers boasting of the ease with
which they fooled market inspectors.
I hope the time will come shortly when all animals must be
slaughtered at inspected plants and that when any disease is
found it will be traced to the ranch or farm that the animal
111 originated from, and furthermore, that the owner be forced to
clean up his herds and flocks and keep them clean.
CHAIRMAN: I wish to thank most heartily all of the people who so generously came to my aid and helped me out in
giving you this programme that we have had this afternoon.
Upon motion the meeting adjourned.   5:30 P.M.
*£S&
112 BRIT^JOINT CONVENTION, BRITISH COLUMBIA, WESTERN AND NORTHWESTERN HOSPITAL ASSOCIATIONS' JOINT CONVENTION,
VANCOUVER, B. O, AUGUST 19th to 22nd, 1930  THURSDAY MORNING SESSION
August 21, 1930
PRESIDING:   Mr. G. W. Olson.
CHAIRMAN:   Mr. J. M. Coady.
The Morning Session was called to order by the Presiding
Officer, Mr. G. W. Olson, who called upon Mr. J. M. Coady, Vice-
President B. C Hospitals' Association, to conduct the Round
Table discussion on Women's Auxiliaries and Social Service.
CHAIRMAN: The first discussion this morning is on the
activities of the Auxiliaries of British Columbia Hospitals, and
I shall ask Mrs. A. C. Wilkes, Convener of Auxiliaries Committee
of The B. C. Hospitals' Association, to present her report.
MRS. WILKES: I wish to present the following summarized
reports:
HAZELTON HOSPITAL WOMEN'S AUXILIARY
Membership—50.
Meetings—Monthly, of all members—not of committee only as
in the past.
Activities—Raising money for special purposes (as indicated in
financial statement); hospital visiting; annual grocery and
fruit shower.
Financial Statement
From January 24th, 1929, to January 7th, 1930
Income:
Balance on hand February, 1929 $ 22.62
Membership fees    52.00
Donation—Sir Henry Thornton  250.00
Other donations     21.50
Proceeds from six functions  606.84
Total  $952.96
Expenditures:
Expenses of entertainments $203.10
Advertising     20.55
Beds and mattresses   296.91
Clock for hospital    24.00
Materials for hospitals, postage, etc  249.35
Christmas gifts for patients      14.85
Balance on hand  144.20
Total  ..$952.96
Respectfully submitted,
(Signed) LILLIAN WRIGHT,
Secretary-Treasurer.
113 WOMEN'S AUXILIARY, ST. PAUL'S HOSPITAL,
VANCOUVER, B. C
Meetings—Weekly.    Average attendance—18 members.
Activities—Sewing, reclamation of gauze (saving of approximately $240.00); objective—to furnish a semi-private ward
and to assist with the furnishing of the delivery room in the
new maternity ward.
Financial Statement
Receipts Annual Tag Day $1,681.66
Amount in charity box      266.40
(Signed)  (Mrs.) NELLIE W. TEDLOCK,
Secretary.
WOMEN'S AUXILIARY, PRINCETON GENERAL
HOSPITAL
Activities—Assisting with furnishing of hospital.
Financial Statement
Receipts—Bazaars and dances $658.40
Expenditures—Linen,   blankets,   infants'   clothing,   etc.,
supplied to hospital  387.70
(Signed) J. M. LEVOCK,
Secretary.
SCATTERED CIRCLE OF THE KING'S DAUGHTERS,
AUXILIARY TO THE KING'S DAUGHTERS'
HOSPITAL, DUNCAN
Memb ership—60
Meetings—Seven sewing bees at the home of members and in the
Nurses' Home.
Activities—Sewing   (1074   articles   made);   linen   shower   (254
articles received); assisted with Hospital Day celebration.
Financial Statement
Receipts from bazaars, etc _ $1,000.00
Expenditures—Greater   portion   of   receipts   spent   for
linen and other supplies for the hospital.
(Signed) (Mrs.) E. FRY,
Recording Secretary.
WOMEN'S AUXILIARY, CHILLIWACK HOSPITAL
M emb ership—100..
Affiliations—Affiliated  with   14   other women's   organizations
throughout the Chilliwack Valley.
114 Activities—Assist with furnishing of wards (35 varieties of
articles purchased, a total of 744 pieces); operate a dining
room at the Fair Grounds; provide Christmas cheer for patients and staff.
Financial Statement
Expenditures  $533.47
(Signed) ELVA GROSSMAN,
Secretary.
WOMEN'S AUXILIARY, NORTH VANCOUVER
HOSPITAL
Membership—74.
Meetings—10 regular meetings were held in the hospital (average attendance 18); 9 meetings of the Executive Committee
(average attendance, 9).
Activities—Purchasing and making up of linen supplies required
for the hospital; regular hospital visiting; arranging entertainment for patients at Christmas and Easter.
Financial Statement
Receipts :
Membership Fees  $ 74.00
Bridge  Tea   110.73
Annual Dance   117.00
Tag Day  292.60
Total  $594.33
(Signed) (Mrs.) J. M. BRYAN,
Secretary.
WOMEN'S AUXILIARY, ST.  JOSEPH'S HOSPITAL,
VICTORIA, B. C
Meetings—Successful year reported.
Affiliations—The Junior Auxiliary.
Activities—From the Auxiliary funds, assistance was given towards painting the hospital, supplying screens, re-furnishing sewing room and ward alterations; special equipment,
such as electric gauze cutter, electric floor polisher, vacuum
cleaner and sewing machines was also supplied. A bursary
has been presented annually to the nursing student obtaining the highest mark in her three years' course.
Activities of the Junior Auxiliary—Assist in social work, decoration of the wards for special occasions; provide Christmas
cheer for patients; contribute to the Nurses' Library and
to the Home furnishings.
(Signed)  (Mrs.) F. J. SEHL,
President.
115 WOMEN'S AUXILIARY, ST. JOSEPH'S HOSPITAL
COMOX, B. C
Membership—40 Active and many more associate members.
Activities—Raised funds for the purchase of several pieces of
expensive equipment for the hospital, such as: obstetrical
bed, incubator, electric stove, bedside tables and linen. A
new feature during the past year was the installation of a
glass cabinet filled with infants' garments; $25.00 was realized from the sale of these garments within a few months.
Present objective, the purchase of several pieces of equipment for the X-Ray department.
Financial Statement
Receipts—Tag Day, Bazaar and Annual Dance, approx. $1,300.00
Expenditures—Equipment, as stated above   1,140.00
(Signed) JEAN PDJET,
President.
WOMEN'S AUXILIARY, MISSION MEMORIAL HOSPITAL
Membership—23 active, 2 honorary members.
Meetings—10 regular meetings held, average attendance 12.
Affiliation—Branch auxiliary, Returned Soldiers Bed Fund.
Activities—Have raised funds by means of which a frigidaire was
purchased, considerable hospital linen supplied and contributions were made towards equipping the X-ray department
and towards the purchase of a new special light for the
operating room.
Financial Statement
Receipts:
Balance forward from 1929   $  797.56
Receipts for 1930   1,472.81
Total Receipts   $2,270.37
Expenditures:
Hospital equipment, etc. (as above)      1,289.86
Bank Balance, June 30, 1930  $   980.51
Branch Auxiliary—Returned Soldiers Bed Fund
Financial Statement
Receipts:
Balance forward from 1929  $439.95
Donation from Legion sale of poppies   109.55
Armistice Bazaar   267.04
Donations and int. on loan to Hosp. Board 106.11
   $922.65
116 Expenditures:
10 returned men cared for during year     234.25
Balance in Bank
$688.40
(Signed)   (Mrs.) J. G. MICHIE,
President.
WOMEN'S AUXILIARY, MATSQUI-SUMAS-ABBOTSFORD
Membership—Successful year reported. A new circle formed at
Matsqui village which assisted the Auxiliary in raising funds.
Activities—Assisted Hospital Board by paying for the frigidaire
recently installed.
Financial Statement
Receipts:
Balance in bank _ $193.45
Sale of flowers      20.20
Tag  Day       25.00
Bazaar  428.34
Concerts      57.22
Membership and sundries        6.24
Donations      95.41
Total Receipts  $825.86
Expenditures:
Hospital Board  $600.00
Matsqui Circle    214.17
Transfer and miscellaneous       5.64
Total expenditures   819.81
Balance in bank       6.05
   $825.86
(Signed) (Mrs.) EDITH M. SHORE,
President.
WOMEN'S AUXILIARY, PROVINCIAL ROYAL JUBILEE
HOSPITAL, VICTORIA, B. C
Meetings—This, the 39th year has been very successful. Regular business meetings 9, average attendance 17; sewing meetings 18, average attendance 15.
Activities—Outstanding work was the furnishing of the large
reception room in the new Nurses' Home; materials for making hospital supplies and special hospital equipment were
also purchased. The Auxiliary presented bouquets to each
of the nurses of the Graduating Class, and Christmas cheer
was also provided for the nurses.
117 Financial Statement
Receipts:
Balance forward from 1929      $1,825.47
Receipts — Tag Day, Membership   fees,   Linen
Shower and cash donations, etc. totalling        1,687.15
$3,512.62
Expenditures—Totalling      $2,403.35
(Signed) MARGARET I. CURRY,
Secretary.
WOMEN'S AUXILIARY, NANAIMO GENERAL HOSPITAL
Meetings—A most successful year is reported. Sewing meetings
were held at the hospital as necessary to make up linen
(material costing approximately $710.00).
Activities—First objective is to supply the hospital with linen;
in addition to this a Universal Refrigeration unit was installed. Arrangements for the entertainment of the patients
at Christmas were also carried out through the Auxiliary.
A linen shower (towels and tray cloths) resulted in generous
donations of these articles.
Financial Statement
Receipts:
Funds raised through membership fees, donations,
sale of Christmas wreaths, tag   days,   garden
party, hope chest drawing, totalling     $1,774.00
Expenditures:
Major expenditures were: Material for hospital
linen, approx     $710.00
Universal Refrigeration unit       $890.00
(Signed)  (Mrs.) J. O. NICHOLLS,
President.
WOMEN'S AUXILIARY, CHEMAINUS GENERAL
HOSPITAL
Membership—The Auxiliary reports a very successful year.
Meetings—Held monthly; average attendance 16.
Activities—Funds have been raised through which the Hospital
supply of dishes, linen, etc., has been maintained at the desired standard. Furnishings for the Nurses' Home have
been purchased, also a General Electric Refrigerator. The
Auxiliary assisted with Hospital Day celebration by serving
tea to the visitors. A special Sunshine Fund (contributions
from members, augmented by sale of holly) provides the
fund from which Christmas cheer for the patients and nurses
is provided, and flowers or books sent to sick members.
118 Financial Statement
Receipts:
Balance forward from 1929   $183.91
Receipts, 12 months (1929-30)  (Hospital Tag Day,
and Lawn Fete, etc.)   .  1,340.45
$1,524.36
Expenditures—Totalling   1,265.14
Balance on hand $  259.22
(Signed) ESTHER B. KOCH,
Secretary.
CHAIRMAN: Our next speaker is Miss Grace M. Fairley,
R.N., Superintendent of Nurses, Vancouver General Hospital,
Vancouver, B. C, who will speak on: ^ • \
"THE VALUE OF A WOMEN'S AUXILIARY TO A
HOSPITAL"
MISS FAIRLEY: Mr. Chairman and Members: I shall only
comment briefly on my personal opinion as a result of my experience on The Value of a Women's Auxiliary to a Hospital.
At the Vancouver General Hospital we have a Women's Auxiliary in connection with the Infants' Department and I am hoping
in the near future that we shall also have for the. General Hospital an Auxiliary, as to my mind, a Women's Auxiliary is of
tremendous assistance to any hospital whether large or small.
From the discussion that has taken place here in the last few
days where we have been discussing finance and efficiency I am
very much of the impression that the Women's Auxiliary is the
soul and the heart of the hospital, and it is very essential that
these Auxiliaries should be formed in order that they may bring
into the hospital that spirit of good will, public confidence and
public interest, without which no hospital can function satisfactorily. The type of work of the Women's Auxiliary depends
entirely upon the needs of the community. There are certain
things a hospital budget will not permit and yet they are as
far as the needs of the patients and the needs of the hospital
itself, very essential, and this is just where a Women's Auxiliary can step in and create a public interest, that will sanction
the purchase of such articles or equipment. Whether the need
is money or whether it be actual active work it does not matter,
whichever it is the Women's Auxiliary can step in. The most
satisfactory type of organization, I think, is where it is well organized and divided up into working committees.    These com-
119 mittees might be social committees looking after the Christmas
concerts and teas, the religious services within the wards, and
anything that will bring personal comfort to the patients. I
might point out another recent need and that is the need that
has been created by the Outdoor Clinics for diabetic patients.
In some localities there may be experienced a difficulty in getting fresh vegetables during certain seasons; they may be expensive and the patients cannot afford them; the Women's Auxiliary could possibly supply the cream and fresh vegetables that
are essential in so many of these diets in the Out-door Clinics.
Then the value of a well organized Library, which is unquestionably a real need of the present day, also the supply of magazines. The Training School Committee is also a valuable committee; it is interested in the graduation exercises and some
times these committees raise funds for a scholarship to send a
student to the University for a post-graduate course; it may also
chaperon theatre parties and look after the dances. Then the
Ways and Means Committee is probably the most important of
all. It has to be alert to the needs of the community and as
to the best possible way of raising money. Some times the needs
are very great in the hospital. Take the question of radium.
There are very few hospitals that are able to get any donations
or gifts with which they can buy radium and yet that is a great
need. The Women's Auxiliary could create a public opinion that
would result in large grants towards the purchase of such things
as radium.
The Constitution should be well defined and should be workable. It should be acceptable to the Board of Directors, and
it should be made possible for each member to have an active
part in that Women's Auxiliary. If members feel that a small
group have always held office and have done all the work, and
that there has been nothing left for those who are equally as
interested in the hospital, your members will soon lose interest.
Meetings should not be less than quarterly and possibly more
frequently if it is an active community. The annual meeting
should be held just before the annual meeting of the Board of
Trustees so that the different reports may be submitted. Possibly the greatest need apart from the working out of the constitution, is that of co-operation and understanding of the difficulties of the hospital. The Auxiliary should understand the
real difficulties and problems of the hospital. I think the Auxiliary should feel they are a part of the hospital and that the
success of the hospital cannot be left to one man or to one woman.
The Infants' Hospital has a very active women's committee which
120 is doing an invaluable piece of work and if the Vancouver
■General Hospital had such a committee, it would be a very great
asset to it.
CHAIRMAN:   This topic is now open for discussion.
DR. MacEACHERN: I think Miss Fairley has touched the
high spots. The Auxiliary, of course, should always work through
the hospital management and through the Superintendent and
work under a constitution and by-laws. The Auxiliary should
not interfere with the management. I feel that the hospital
authorities should take the members of their Auxiliary through
the hospital and show them the various departments; arrange
possibly to have talks to them and perhaps by demonstrations
show them what is going on in the hospital. I leave that point
with you. I do not care if they raise any money or not, it is
their influence which is the great potential factor of value to
the hospital.
DR. ALEXANDER: I was very much interested in the
remarks made by Miss Fairley and also by Dr. MacEeachern.
I believe the hospital situation in Canada is altogether different
to the situation in the United States. Practically all of our
general hospitals are more or less political and naturally when
politics enter into any hospital there is always more or less antagonism and criticism which one must face. The best way to
face that criticism is through the women and we have found
that our Ladies Auxiliaries have not only helped to see that the
patients of our various hospitals are properly taken care of, but
they have also done a great deal to disarm any criticism from a
political standpoint that might be made of the institution and
its administration.
MR. McVETY: I feel that this movement of organizing
Women's Auxiliaries is a very good thing for the hospitals and
as far as the British Columbia Hospitals' Association is concerned we will do anything we can at any time to assist in
the organization and directing of the work of the Auxiliaries
to the hospitals.
MR. FOLEY: In the United States we have found that the
Ladies Auxiliary is the most common form of hospital aid and
hospital educational activity. In a recent survey of about 540
hospitals it was found that 78 per cent, of these hospitals had
ladies auxiliaries and yet it remains for the Hospital Associations of Canada to recommend that they should be established
as an assistance to the hospital administration.
SISTER GABRIEL: I think possibly the hospital administrators might take this question to heart   and   ask the ques-
121 tion, "Do they always co-operate with the auxiliaries as they
might?" Are they not often considered as not helpful and as
a body of people who know nothing whatever about the hospital and who are constantly interfering with the administration?
Should we not ask ourselves these questions? I do know, perhaps better than any one else, what a wonderful assistance the
Ladies' Auxiliaries can be to the hospitals and to our schools of
nursing. We have an auxiliary in Seattle of 3000 members with
a membership fee of $3.00 a year. They are instrumental in
getting up very high class entertainments, teas, etc., and they
come in contact with people who have money and we feel that
we owe a great deal to our auxiliaries, and we can always look
to them for co-operation.
CHAIRMAN: I am sure we all regret that Miss Amelia
Feary of Portland, Oregon, Director of Social Service, Doern-
becher Memorial Hospital for Children, is unable to be present
this morning. Miss Carolyn E. Davis has kindly consented to
read Miss Feary's paper on the subject of
"THE VALUE OF A SOCIAL SERVICE DEPARTMENT
TO A HOSPITAL"
In attempting to evaluate a social service department, it
might be well to be sure that we have a similar understanding
of the various services which a social service department is able
to contribute to a hospital. These services are very practical
and definite, and no doubt are familiar to all of us. Reviewing
them briefly, I should say first, securing social information;
that is, data concerning the personal and family life of the
patient and the problems confronting him. This may be gathered from the patient himself, from members of his family, teachers, pastors, social agencies, etc. Second, the interpretation of
these facts so that the patient may be understood not only as a
medical case but as a human being. To what extent has he
developed, psychologically and socially? What can be expected
of him in carrying out medical plans for treatment? What
help does he need in straightening out some of his social problems so that the cure can be effected and further illness prevented? Third, carrying forward a plan in conjunction with the
physician and the patient, in which the medical and social phases
are correlated. Sometimes this involves direct contacts with the
home and with other persons interested in the patient. Sometimes it means putting the plan before some social agency in
the community which is so organized that it can carry on this
work. Sometimes a co-operative scheme is necessary when there
are several agencies in the community whose functions overlap
122 somewhat, but all of whose services may be needed to develop
the plan in mind. For instance, it is not at all unusual to find,
in a community that a patient has the interest or should have
the interest of the relief agency, a court, the visiting nurse, the
visiting teacher, a day nursery or a baby home. A definite
understanding must be reached with each agency, as to which
part it is to play. This necessitates conferences with these
agencies with a closely dovetailed plan, and requires, not only
a discriminating knowledge of functions of various social agencies, but a friendly and close acquaintance with the workers of
these agencies.
These, as I see them, are the major services to the hospital.
Out of these grow some by-products considered by some perhaps
to be of major importance; such as continuous and regular clinic
attendance, which is the natural outcome of contacts with the
patient and his family, in following out a medical-social plan, and
of our interest in him personally. The determination of fees,
or the proportion of the cost of the doctor's services, or of the
hospital care, to be paid by the patient, is also considered by
some to be a service which the social worker can easily render,
because facts concerning the economic condition of the patient
form a natural part of the social investigation.
Is a social service department necessary to a hospital? Is
its value so essential that the hospital could not function to
its best and fullest capacity without it? Considering the matter from the scientific angle alone, it has been demonstrated
that the cure of the patient becomes effective with the aid of
the social worker, when otherwise it would not. Many illustrations could be drawn to show, for instance, that without the
social worker's assistance in procuring material relief for a
family, a malnourished baby could not be supplied with the
necessary diet prescribed, that a laborer with a heart condition
would soon return to the hospital in a worse condition, unless
adjustment to employment were engineered by the social worker.
In helping to make the cure effective for the patient, in a large
majority of instances, conditions are found in other members
of the patient's family which the social worker recognizes and
brings to the attention of the physician and preventive work
is possible. This holds true not only for patients in poor circumstances but for private patients also. Many times the service rendered by the social worker has to do not with problems
incident to lack of funds or lack of earning ability, but to mental attitudes based on past experiences, or to character deficiency. There is no question that from the purely medical standpoint, a social service department is of very practical assistance
123 in prevention and cure of physical conditions requiring treatment. It is my belief that the time will come when physicians
will more fully recognize the value of professional social service,
as it is developed today, in the cure of patients, and make more
extensive use of it in their private practices, in office, home
and hospital.
There is, as we know, some difference of opinion as to
whether the determination and collection of fees is a legitimate
part of the hospital social worker's job. Whether or not this
definite function is assigned to the social service department
in a hospital, there can be no question that the fundamental information upon which a decision is based can be secured more
intelligently and with better results, as a natural part of the
social investigation by the social worker, than by any other
means. The hospital which has this service at its disposal, should
secure a larger proportion of fees from patients and do so in
a manner that is more just and humane, than the hospital which
relies entirely upon its business department for such a service.
The foregoing seems to me to justify the existence of a
social service department and to make it of essential value to
a hospital, regardless of the hospital's status, as a private or public institution, for rich or poor. But as P see it, the largest contribution which a social worker in a hospital can render is the
interpretation of medical science and its findings to the social
agencies in the community and the interpretation of social problems and their solution to the medical group in the hospital. If
a hospital has a social service department, the whole scope of
its function in the community is enlarged, so that it takes its
place as a social agency in the community rather than as a strictly
scientific institution.
CHAIRMAN: Discussion of this topic will be postponed
as the subject of the next address is very closely related to it.
The final speaker of this part of our morning session is Miss
Elizabeth MeKinley, Field Director, The American Red Cross.
Miss MeKinley is at present stationed at the U. S. Naval Hospital, Bremerton, Washington. I have pleasure in introducing
to you Miss MeKinley who will speak to us on the
"FUNCTIONS OF THE HOSPITAL SOCIAL WORKER"
MISS McKINLEY: The functions of a hospital social worker
have been discussed wherever and whenever two or more hospital
social workers meet, largely because medical social work is one
of the newer branches of case work and because, in many instances, we are still feeling our way. In the hospital' where there
is a newly organized social service department we are quite likely
124 to pick up all sorts of tasks, not always because they belong to us
but because there is no one else to do them. Some we are sure are
ours, others we feel quite definitely could be done equally well
by an untrained person, and still others lie in a debatable field.
It may be necessary in order to fulfill the hospital's obligation
to the patient to do tasks that do not require a social worker's
training, such as looking after lost clothing and making purchases for patients, but it scarcely seems fair to the patient, the
worker and the doctors to take the social worker's time for
errand running.
In some clinics and hospitals we find the social worker acting as admission clerk. This job does give the worker opportunity to discover social problems which may be detrimental to
the patient's recovery, but it also involves the doing of much
routine clerical work which could be done equally well by an
office worker. We also find social workers doing the job of a
financial investigator and determining the patient's eligibility to
free or part-pay care. Other tasks which seem to lie in the debatable group are friendly visiting in the wards; home visiting
when the family is under the supervision of another agency; supplying comfort articles, clothing and administering relief, notifying relatives of seriously ill patients and carrying the responsibility of a project which is mainly medical research.
This last item brings to mind an instance which I recently
experienced. An elderly man, native of Germany, died and the
results of the autopsy showed the cause of death to be the larvae of the pork tapeworm in the brain. This was extremely
interesting to the medical officers as the larvae of this particular type ordinarily develop in hogs and the adult worm in
humans. Because this man had a dependent family we had secured a brief social history and learned that he had left Germany 30 years before, and that several years after his arrival
in America he owned a butcher shop. However, we also learned
that his mother, his brother and sister had all exhibited similar
symptoms to his before their deaths. The medical officers desired the details of these other cases as! there seemed the possibility of the original infection taking place over 30 years before
the man's death. The patient's wife knew nothing of his family
but there were many letters from his relatives dating from his
arrival in America to 1914. As there was also a possibility of
an inheritance in Germany we undertook to translate this volume
of correspondence. After this tremendous work was done we
had found nothing of significance to the family, but we had
secured the names of the hospitals where the brother was treated
and finally died as well as the name and address of the last
125 correspondent in 1914. The question then was should the social
service department start correspondence with the Red Cross of
Germany to attempt to locate the relatives and to secure the
medical report from the hospital to assist the doctors in their
research project.
The social worker's primary objective is, of course, to assist
in making medical treatment effective. Her first job in fulfilling that objective is to aid the patient in adjusting to hospital
routine. The hospital is very different from his home life, the
patient himself is not in his usual normal state. He is likely to
be querulous, exacting and apprehensive. The busy doetor has
time only for the treatment of the patient's disability, the nurse
can only be concerned with carrying out the doctor's orders
and running the hospital ward. The social worker must take
the time to explain the reasons for that particular part of the
hospital routine which is causing the patient so much difficulty.
Her position is that of an interpreter between the patient and
the hospital.
The worker frequently continues the role of the interpreter
in her relations between the patient and the doctor. In taking
the social history she gets a picture of the man's background and
home life which will explain in large part why he is an unwilling
or unco-operative patient or why he is not reacting well to treatment. Her function as an interpreter is carried on to the family
who cannot understand why their formerly amiable father is now
irritable, listless and indifferent to their plans and activities.
Finally, she acts as interpreter between the patient and the medical group and the other agencies interested in the family. She
carries the doctor's recommendations to the family case worker,
or whatever agency is represented, and explains why certain
apparently abnormal reactions are normal to a given situation.
To carry out her role as interpreter successfully .the case
worker must understand the significance of disease. It is not
her province to know symptoms for the purpose of diagnosis,
but it is absolutely necessary for good case work to know the
meaning of symptoms as they will affect the patient in his relations with his family and community. She must remember that
there is a definite nerve reaction after a major operation, that
weakened vitality is accompanied by depression and apparent
lack of ambition. She must understand the type of handicap
which a certain disability usually involves then suit her general
knowledge to the particular case of her patient.
If the worker has this understanding she will be able to complete what seems to me a most important part of her job of assisting in making medical treatment effective.    How many times
126 have we seen a man with organic heart disease, for instance,
spend weeks under a rigorous hospital regime, be discharged from
the hospital in fair condition with many symptoms entirely disappeared only to return within a short period worse than at the
time of his original admission. If the social worker goes thoroughly into the man's home conditions and his occupational situation, she may be able to set the machinery going which will
enable the man to keep his independence and his health and save
further hospital care for an indefinite period. To do this part
of her job it may be necessary for the hospital social worker to
continue her interest in the patient after he has left the hospital
or clinic, but in cities where other agencies are available the case
can usually be transferred.
While the hospital social worker is acting as go-between for
the various individuals and agencies concerned she is, of course,
doing her job of case work, which in itself differs in no way
from that of a worker in any social agency. She elicits the confidence of her patient and his family, goes into the details of
his present difficulty and his background, submits her findings
to a thorough analysis, makes her social diagnosis and plans her
treatment. Her diagnosis is colored by the medical situation and
her plan of treatment should be formed only after consultation
with the physician in charge.
The worker also has a definite responsibility (to the community in allying herself with groups concerned with the prevention of illness and with education in general principles of
physical and mental hygiene. Her work with volunteer groups
and clubs gives her an excellent opportunity for educational work
and her training of students from the nearby school of social
work helps to complete the dual role of social worker and educator.
CHAIRMAN: These two papers are now open for discussion.
DR. MacEACHERN: I was very much interested in these
last two papers concerning the work of social workers. These
workers have humanized the admitting office and have also emphasized the importance of the position of hospital hostess which
in the small hospital is taken on by the Superintendent, and in
the large hospital by a special person set aside for it. Doctors
who are practising medicine to-day should write as many prescriptions for social service care and investigation as they do for
drugs and medicine. If I ever practise medicine again I shall
write prescriptions from the social service worker's point of view
on the case which I am treating.
127 DR. ALEXANDER: The value of the social service worker
depends upon the size of the community. The smaller communities perhaps are not interested in this problem because every
one knows every one else. But in the larger cities the work done
by the social worker is very valuable, and cannot be measured
by what she finds out about the hereditary diseases, the home-
environment, etc. It is a protection to the institution and the
public at large from the standpoint of preventing indigency. In
the larger cities this problem of indigency is one that must be
met and is one that is of vital interest to the medical profession.
If the doctors can be shown how they are going to be affected
in the matter of dollars and cents, by the protection of their
practice by the use of social workers, they will be in favor of
them. In our city we have a number of people come into our
hospital who do not properly belong there. In the past these
people have been allowed to come there and have their hospitalization free. These people could quite well afford to pay for
their hospitalization and it has only been from the close application of the social service worker and by very close supervision
that we have been able to turn these individuals back to the
doctors to whom they rightfully belong. The social service
work is really in its infancy and I feel that we cannot praise the
well trained social service worker too highly for the work that
she is doing and the opportunities that still exist for them.
MISS RANDAL: I would like to ask Dr. MacEachern whether he feels that it would not be an advantage to have the social
service worker a graduate nurse. These patients being ill require more or less nursing which experience the nurse gets in
her three years' training.
DR. MacEACHERN: No question about that. The nurse
who takes the proper training for the social service worker would
be of inestimable value.
CHAIRMAN: May I thank all those who have contributed
to this part of the programme this morning. This Round Table
is now adjourned.
OPEN SESSION—10.30 a.m.
PRESIDING:   Dr. M. T. MacEachern.
CHAIRMAN: We have with us this morning Mr. C H. Gibbons, Secretary, Royal Commission on State Health Insurance
and Maternity Benefits. Mr. Gibbons will discuss a subject which
128 is of vital interest to all of the members of the B. C Hospitals'
Association, that is the question of the
"EFFECT OF STATE HEALTH INSURANCE ON
HOSPITAL FINANCES AND ECONOMIES"
MR. GIBBONS: Mr. Chairman, Ladies and Gentlemen: It
gives me great pleasure to be present here to-day with three associations whose members have done and are doing so much toward the relief of suffering humanity and contributing so largely
of time and thought to the betterment of hospital conditions and
the advancement of hospital science. I have been asked to say
something on the aspects of state-health insurance, more particularly as such insurance reasonably may be expected to affect hospital finances and economies. In this connection I act as a substitute, a pinch-hitter, inasmuch as the Royal Commission of which I
am secretary just now is engaged with field work in the North
and unable therefore to participate in this interesting convention,
as otherwise some at least of its members undoubtedly would. The
present tour of this Commission is the last in the course of which
opportunity will be afforded individual citizens and public or
semi-public organizations to express their views and offer constructive suggestions in connection with health insurance proposals. The ground of inquiry has been, I believe, fairly well
covered; and although anything I may say must necessarily be
"sub judice," as it were, material for the Commission's final report not yet having been considered, it can at least be stated without trenching upon the probable scope and tenor of that report,
that throughout British Columbia and among all classes and interests of the provincial community there has been evinced an
overwhelmingly preponderant opinion that a system of public
insurance against losses by illness should be devised and applied
without delay, in the interests not only of residents of limited
means, but equally of economies in provincial and hospital services and as a step toward the reduction of the costs of medical
care, of protecting the hospitals against inevitable bad debt losses,
and for scientific reduction of the volume of preventable sickness and the building up of a healthier, happier and more progressive community.
"There is no dissenting opinion, even on the part of life
insurance managers, that government insurance has resulted in
far-reaching reforms," says Mr. Frederick L. Hoffman, the eminent American insurance expert, "that government insurance has
been of vast benefit to the people, and that it has come to stay;''
while Dr. Michael M. Davis, director of the Julius Rosenwald
Fund, supplements a like expression of considered opinion by
129 stating that '' in the fact that sickness and its costs are unevenly
distributed lies the necessity for applying the insurance method
of protecting wage-earners more particularly. There is no substitute for social insurance in economically distributing the costs
of illness.".
At the same time careful study of the character and scope of
the various schemes of health insurance obtaining in Great Britain and advanced foreign countries, and necessary evolutionary
changes in such schemes produced in operative experience, lead
inevitably to the conclusion that any plan of state-health insurance to be effective must be compulsory. Voluntary insurance
against sickness now is and long has been available in Canada
through the enterprise of private insurance companies, fraternal
societies, labor organizations, etc.; and our own national experience has demonstrated, as such experience has also in other
lands, that the very classes and individuals who have most to
fear and most to lose through interruption of their regular employment by sickness, those least competent to sustain sickness
loss, are those who constitutionally take no! rthought of the. mor--
row and are content to let their more provident and more prudent
fellow-citizens not only provide against the possibility of sickness in their own homes, but make up the deficits in doctors'
and hospital bills created by the neglect of such improvident ones
to take thought of the always possible rainy day.
The conclusion may safely be drawn that the British Columbia Commission on state-health insurance now functioning will,
in reporting to the Legislature at its next session, recommend, as
in the general' publie interest, the enactment of a compulsory
system of publie health insurance devised to meet as best may
be done the special and peculiar conditions of this province of
vast distances and scattered population centres, of struggling
farming and fruit-growing interests, and of industry-f ounding'
pioneers of the hinterlands — the British Columbia state-health'
insurance problem in these respects being distinct and original,
neither to be copied nor adapted on precedents in the legislation
and practice of older and long-settled countries.
It is to be noted, also, on the evidence of the Commission's
research work thus far accomplished, that provincial opinion as
to state-health'insurance has materially changed during the past
few years;-with'more general study and fuller understanding of
the subject. Whereas ten, or even five years ago, the common
if unconsidered opinion of industrial and general business interests was that state-health insurance in operation would be merely
another example of paternalistic legislation for the special advantage of certain classes of workers, further adding to the operat-
130 ing charges of already over-taxed industries, the majority conclusion of such business interests now is that whatever fair proportion of necessary premium charges employers may be called
upon to shoulder will be offset by benefits to the industries as
well as to workers therein. Municipal corporations of British
Columbia are found to be 100 per cent, in favor of state insurance against sickness losses; and .the Canadian Manufacturers'
Association members in this province, hitherto inexorably opposed to state-health insurance proposals, have now by ten-to-one
endorsed the initiation of a practical scheme in such connection.
The earlier disposition was to accept it as axiomatic that if employers were to contribute to the costs of health insurance protection for their workers, overhead expenses inevitably would
be increased. In this attitude the facts would seem to have been
overlooked or ignored:—
That a wider spread of insurance by its general application
on actuarial principles should reduce the average cost to below that now possible under existing voluntary employees' benefit association schemes;
That administration costs of such services will be eliminated;
That equities now missing in the operations of competing
interests will be assured, to the marked advantage of employer
bodies actively interested in the welfare of their workers;
That employers will gain by decreased interruption of the
sustained capacity effort of their working forces, through betterment of health standards, anticipating and preventing the development of illness, enhanced general efficiency born of relief
from workers' worry, and extension of the span of activity for
experienced employees;
That reduction of abnormal charges now carried by the Province and by municipalities in connection with health protection
and care of the sick, aid for hospitals, and physicians' subsidies,
through a considerable proportion of such charges being assumed
by established insurance funds, will in turn be reflected in reduced taxation in such behalf now indirectly borne by industrials, etc.; and
That a major portion of the sickness costs burden now placed
upon Province and municipalities through non-payment of hospital charges will be extinguished with such charges being made
100 per cent, collectable by the health insurance machinery.
There is, too, growing appreciation by the heads of important
business interests of the dollars-and-cents advantage of doing
everything humanly possible to maintain industrial workers in
131 full health and fitness — this not as humanitarianism and not
as benevolent charity, but as essentially sound business policy.
"I admit to an obsession in this regard," wrote Sir Henry
Thornton, not long ago, "If a railway tie can be given longer life
by creosote and a railway car by paint, then a human piece of
material can be enhanced in value and serviceability in the same
way.''
Early in the present Commission's investigations, when an
analysis was undertaken of every piece of state-health insurance
legislation and every concrete proposal in that connection the
world over, one circumstance intruded that makes the provincial
position at once unique and more difficult than ordinarily: all
precedents as to state-health insurance legislation are in a measure inapplicable inasmuch as such operating legislation is universally national, not state or provincial. Great Britain has its nation insurance system, which has so functioned, despite some natural defects, as to lead the Chief Medical Officer of the British
Ministry to testify that'' the value of health insurance practice is
beyond all question." The Irish Free State has a like system.
The Union of South Africa is taking steps in the same direction.
Australia is moving similarly, the states of the Commonwealth
rejecting as impossible of consideration the suggestion that such
protection for citizens of limited means should be other than national. In Canada the concensus cf available opinion is identical
— that there should be public-health insurance, and that such
insurance should be a Dominion obligation and a Dominion responsibility.
This has been emphasized on the one hand, before the parliamentary Select Standing Committee on Industrial Relations,
by President Tom Moore of the Trades and Labor Congress of
Canada, representing the employees' class, and on the other hand
by Mr. Coulter for the Canadian Manufacturers' Association,
speaking for the employer body. These are agreed that any
state-health insurance scheme should preferably be Dominion-
wide, else the business interests of participating provinces might
conceivably be penalized in competition with like business interests of non-participating provinces, much as certain Ontario business interests, the garment trade more particularly, are penalized by the operation of a minimum wage law non-existent in
Quebec. The Department of Justice maintains, however, and its
ruling is insisted upon by the Dominion as final, that jurisdiction in all such legislation rests exclusively in the provinces, by
virtue of the British North America Act, which is Canada's Great
Charter, although it would admittedly be within the constitutional right of the Dominion Parliament to make grants from the
132 national Treasury to the provinces or any of them, as partnership contributions in financing, should state contribution to costs
be made a factor in any adopted provincial health insurance
scheme.
The former federal Minister cf Labor, Hon. Mr. Heenan,
voiced the attitude of the Dominion Government of which he was
a member in saying that "the Dominion should wait for the
provinces to take the initiative," special cognizance being taken
of and stressed by the federal Committee as to British Columbia
having already given such a lead in this suggested new social
legislation, as in the somewhat parallel Old Age Pensions law.
The Dominion is now committed to the principle of state-
health insurance by the government's and by parliament's unanimous adoption of that portion of its Committee's Report in this
regard; but that Committee found its inquiries handicapped by
inability to secure authoritative data on the extent and costs of
sickness in Canada, the non-availability of any concrete project
upon which actuaries could prepare statistical information, and
the infrequency of helpful census compilations, as a result of
which the recommendations have been adopted at Ottawa that
a comprehensive survey of the field of publie health activities
be made with special reference to a national health programme,
and that in the 1931 census provision should be made for securing the fullest possible data as to the extent of sickness and sickness costs, presumably with a view to Dominion action. The Dominion is committed to the initiation of such a Canada-wide
health survey, and to making proposals for state-health insurance a matter for consideration at the next Dominion-Provincial conference. It is therefore reasonably to be hoped and naturally expected that in the development of whatever form of
health insurance the British Columbia Legislature in its wisdom
may enact, in the event of this providing for state contribution
to costs, the Dominion will assume such charges in whole or
in part, although this could not be expected in advance of information obtainable as a result of next year's census.
It is assuredly high time that the nation's legislators took
steps for the reduction of the national sickness charge, now
placed at more than $311,000,000 annually, and the decreasing
of medical and hospital costs, particularly when such sickness
costs and economic loss to Canada are placed by so competent
a student as Dr. Gibbon, M.P., of Bracebridge, at no less than
from two-thirds to three-fourths of the total expenditures of the
Dominion—when Canada's (hospital up-keep bill exceeds tw,o
hundred and fifty million dollars annually and is steadily mounting, and when so informed an economist as Mr. H. H. Williams
133 of Toronto puts the yearly loss of future earnings through preventable deaths at the enormous total of one billion dollars, with
two per cent, of the population constantly ill, 50 per cent, of this
illness preventable, and at least 35 per cent, of our deaths each
year postponable by intelligent protection of the health of the
people.
How are reductions of these costs and losses to be effected
by the application of state-health insurance? Primarily, if the
lessons of state-health insurance practice in other countries are
given heed, by a systematic revision of health services with primary attention to keeping the people well. Sir Arbuthnot Lane
urges that the medical profession must revolutionize and reorganize its principles and its policy with recognition of this objective. Dr. W. S. Rankin, the successful director of the Duke
Foundation, declares that "the insurance principle appears to
be the only remedy, but a most effective one, for providing adequate medical care for a very large percentage of the people."
And Mr. Woodsworth, M.P., has told the Canadian Commons
that "under a thoroughly organized national system of state-
health insurance there would be many economies; there would
be much preventive work that would naturally lessen the bills,
and yet on the other hand there would be a much more extensive
and thorough service than can now be provided."
While the science of healing has been making tremendous
strides, the business of healing has woefully lagged behind.
Economists and industrialists are becoming more and more seized
of the necessity of checking the enormous wastages in sickness
costs preventable by such a system as will assure closer and
more continuous observation of the units of the industrial population, through which incipient disaffections may be detected
and headed off, with prolongation of the working span of life
and increase of years, comfort and effectiveness. This is peculiarly a function of public-health insurance machinery, and
claims are advanced in Europe that the operation of compulsory
health insurance, with associated health preservation and education propaganda, have lengthened the normal employment life
of industrial workers by from seven to seventeen years. Periodic
examinations, an important feature of a sound health insurance
plan, detecting and preventing threatened disease ere it assumes
control, should reduce cases of sickness now demanding medical
and hospital care by easily 20 per cent. The circumstance that
payment of bills is assured by the guarantees of state-health
insurance, the spectre of bad debts thus being exorcised and an
average loss extinguished of—shall we say 30 per cent?—must
go far toward the reduction of hospital costs.   That element of
134 bad debt loss has to be made, up by someone. With its elimination the necessity of provincial aid to hospitals': should almost,
if not entirely, disappear. With its elmination also it. would
reasonably be expected that cost reductions could be achieved.
jfe- Again, the trend of health insurance practice! has so materially changed of late years that the gain thereunder to hospitals
and the medical profession parallels that of the mind-at-ease insured person. Originally the primary objective1 Of such largely
experimental insurance plans was to provide partial dash compensation for wage losses sustained through sickness. Now the
factor of benefits-in-kind—medical and nursing care, hospitalization, laboratory and X-ray examinations, etc., etc.—is playing a constantly more important part. As to the use.of reserve
funds balances in excess of amounts assuring ability to meet all
normal insurance carrier obligations, it is becoming standard
practice to divert available surplus moneys to health extension
works excepting in those countries which proportionately reduce
the levies for sickness insurance as reserves are accumulated for
its specific purposes.
Australia stipulates that such accumulated surplus funds
may be used "in the extension of social services available to
insured persons." Austria designates their employment "to provide improved health conditions of the insured population."
Germany authorizes their use "for general purposes of disease
prevention." Greece follows a similar course. Hungary directs
their use in "establishing and maintaining institutions for the
relief of the sick"; while Denmark prescribes that "when, at
the bidecennial survey of insurance affairs, it is found that the
reserve funds are in excess of requirements, with due allowance
of a safe margin for emergent demands should they arise, appropriations may be made therefrom for the establishment of sanatoria or hospitals or convalescent homes, or for the furtherance
of other measures, educational or otherwise, for the scientific
prevention of disease or the reduction of sickness and the general improvement of the country's health standards."
There is also to be taken into consideration the established
economy of quantity purchasing. Health insurance science on
the compulsory principle and with its application to the mass of
population, with its wide spread of contribution, should as surely
reduce costs to the individual citizen as chain store buying and
selling of merchandise. Intelligently and honestly functioning,
monetary provision for the costs of sickness should be made
much more cheaply under a state-health insurance system than
is possible at best through, individual forethought; while the
135 security to the insured, to doctors and to hospitals, is at the
same time perfected.
Elimination of the profit element—state insurance operating without more than administration cost—will go far toward
economies. In British Columbia last year sickness insurance
losses of $151,713 were paid by casualty insurance corporations,
as against gross premiums of $226,693. Agents' commission on
such insurance business is normally 30 per cent minimum, with
additional branch office charges of ten per cent., advertising ten
per cent, more, and other promotional activities of the business
bringing down the deduction from payments made by the insured for his protection from fifty at least, and more often sixty
per cent. And this does not take into account shareholders'
profits, which the reports show to be, in the main, highly satisfactory. The insured person therefore gains proportionately
under state insurance, which seeks no profit, and the capacity
of such insured person to meet his obligations, to doctors, to
hospitals and to others, rises in corresponding degree.
MR. McVETY: Mr. Gibbons, on behalf of the British Columbia Hospitals' Association, I wish to thank you for coming
to our Convention at this time to discuss a subject which is
'more or less "sub judice" and for the frank way in which you
have dealt with this matter this morning.
DR. RIGGS: I would like to tell those who are interested in
the medical men's standpoint in this Province to get the Convention Number of the Canadian Medical Journal for this month.
You will find there a letter from Dr. J. H. McDermott of this
city setting forth the point of view of the medical men of this
province with regard to this situation.
CHAIRMAN: I am interested in a form of health insurance that will protect the hospital and the person of minimum
earning power and the medical profession in carrying on its profession as independent practitioners of medicine. I am sure that
will be the form that will be popular with the public.
CHAIRMAN: Our next speaker is Dr. G. A. Ootmar of
Kelowna, B. C Dr. Ootmar is a Medical Health Officer and
Bacteriologist of the Province of British Columbia and the title
of his paper is
"THE FORGOTTEN ROOM"
DR. OOTMAR: It sounds like a tale from the Arabian
Nights — "The Forgotten Room" — I did not choose this subject for my lecture to stir your curiosity — but because nothing
136 is more true than that in nearly every hospital a room is forgotten.
When the Matron leads the visitor around the hospital, she
shows with pride the wards, the semi-private and private rooms.
She shows the operating room, even in small hospitals. She
visits with you the X-ray room — but one room which is needed
so very badly is missing — the room where researches are done.
I did not call it the Laboratory because I like to save this name
for bigger hospitals.
We miss this researching room in the small hospitals; it is
here that researches are done. Often you find in a bathroom
a small cupboard with three bottles and a test tube, one bottle
with a cork — colored yellow on the underside, the nitric acid
— two bottles with Fehling's solution — the outfit for research
in many hospitals.
Far from expecting in every hospital a complete laboratory,
we must agree that the laboratory conditions in many hospitals
are quite insufficient and that it seems an urgent need to improve these conditions. But even those hospitals which see
plainly the need of better laboratory facilities, do not see how
it could be possible to erect even a very small laboratory and it
is about this possibility that I shall have the pleasure of speaking
to you to-day.
Before I come to this, you will allow me to speak to you
about the very good help a small laboratory would be to you.
We are in a small town with a hospital of 25 beds. A
patient is brought in unconscious — found on the road. The
smell of aceton from his breath suggests that he might be a diabetic found in diabetic coma. There is no urine to test and
how valuable would it be to know if our insulin — of which we
Canadians are so proud as it is a Canadian product — perhaps
might help. A few cubic centimeters of blood — and the percentage of sugar of the blood could be determined within a half
an hour — deciding the question, insulin or not.
Another day a patient is brought in with pain in the abdomen. The doctor is in doubt whether it is appendicitis or perhaps a kidney stone or something else. If he only could have
had a complete urinanalysis done, to see if there are any casts
in the urine or if there are leucocytes, which give the doctor
the diagnosis of pyelonephritis, or pyelocystitis and the analysis
of the sediment may give the suggestion of the nature of the
stone. The pain continues. Can a man with a kidney stone
or pyelonephritis not suffer from appendicitis too? It is true,
the pain is not exactly on MacBurney's Point, on the typical
137 spot, but in how many appendicitis cases did we not find the
pain too high or too low for the typical point? A blood count,,
if this were possible, would solve the problem. Above 15,000,.
operation; under 15,000 we can still wait.
Once, years ago in my native land, a patient was brought
in with a severe pain in the abdomen, with all signs of "facies.
hippocratica," I do not know if you call this condition in which
the patient's extremities are continually cold by the same name
as old Europe does — a very severe condition but nobody knew
what was the cause. The blood count was 22,000 and from the
small room which was saved for a Laboratory came — not the
old C.Q.D. (S.O.S.), — come quickly, danger, — but O.Q.D., operate quickly, danger. A pancreatitis was found, the capsule cut.
Never a patient's life had a narrower escape, than it had in this
case, where it just passed the border between life and death,,
and where the laboratory was the pilot which guided the doctor
to a safe harbor.
A child has fallen ill, the doctor is called. There is a small,,
white spot on the tonsils. There is slight temperature, there is
perhaps — it does not look — it does not seem — but, perhaps,
it might be — it is nearly impossible to think — but one can
never know — it might be diphtheria. But there is no other
case, it is so doubtful, that the doctor cannot decide to inject
the child with the serum le Roux. Next day the tonsils are all
covered, fetor is present, also difficulty in breathing, diphtheria
is prevailing. Immediately the serum is injected, let us hope not
too late. A swab taken the previous day, would have given the
doctor the warning of the possibility of diphtheria from the
very first moment and perhaps would have saved a life. Saved
a life and saved the spread of the disease, because the sooner
We know that an infectious disease is prevailing, the sooner we
can stop the spread of disease. Don't say, "But the doctor can
do this. The doctor knows or must know, how to distinguish
the germs." Ladies and gentlemen, I was a doctor for years,
for many years a laboratory man. I know too well, that both
occupations cannot be combined in one man. For the laboratory we need the quiet worker and when the doctor after a
busy day comes home, it is impossible to expect him to do
laboratory work. I know there are doctors who do it, but why
consider the exceptions? As a rule, we can say that the doctor
has no time to do it and even when he has time, he would lack
the experience which enables him to do the work with ease,
that he feels safe in his researching:.
There is a patient thought to be suffering from typhoid;
if only a Widal could be taken, a blood culture made!   There
138 is a patient with.a discharge — the doctor would.like to know
whether it is gonorrhea or not. There is sputum to be examined. You will say the doctor can send it to a laboratory. We
know too well that because of the distance between hospital and
laboratory, few specimens are sent to the laboratory, that the
greater the distance between the hospital and laboratory, the
longer it takes before epidemics are stopped.
The forgotten room! The forgotten laboratory would stop
this. But it is not the room alone which has to be found, it is
its equipment too — the salary for the laboratory men. We all
know how every hospital in British Columbia has to struggle
to make ends meet, and no one can think of increasing the heavy
burden of the hospital by the fees for laboratory work. We have
tried to solve this. We have started in Kelowna a training school.
We do not call our trainees "technicians" but just laboratory
aides. We teach them to do the most urgent and easy tests. We
do not teach them a Kahn, or even the more simple Meinicke
test for syphilis. We do not teach them about the behaviour of
germs of the typhoid or salmonella group fermenting different
sugars. We just teach them the most necessary laboratory tests,
the tests which cannot wait for the report of the big laboratory
to which the specimen otherwise would have to be sent. We
know that it is dangerous to teach too much and we do our best
to concentrate our trainees on the laboratory work they have to
do later on by themselves. We do not like to train them to be
laboratory assistants, laboratory aides is what they have to be,
because with the laboratory work they must know or learn something else in connection with hospital work — nursing, bookkeeping, dietetics or housekeeping. The laboratory aide has only
a few hours in the morning to stay in the laboratory, the rest
of the day she can be occupied with other work. She can do
secretarial work or bookkeeping; she can be of help in hospital
or nurses' home. Even a small hospital can in this way afford
to have a laboratory aide.
The equipment of a small laboratory does not cost as much
as many believe. Without counting a microscope the cost will
not exceed $150.00. When we started our laboratory we used our
own microscope and got two other ones from the local doctors.
I suppose we can omit the cost of the microscope, the heaviest
one. We started, as I told you, a training school for laboratory
aides in our provincial laboratory at Kelowna. I never hope one
will say that Kelowna has a training school for laboratory assistants or technicians; we. only lay the foundation. Our course is
nine months, in which we teach the trainees to do complete
urinanalysis, bloodcounts, examination of milk — chemical and
139 bacteriolgical; Widal and blood culture in typhoid, sputum examination ; examination of smears for gonococci; examination of
swabs for diphtheria and scarlet fever, the determination of
germs in abscess, the detection of blood in feces and urine, and
blood counts.
The course is free; up to now the students had to provide
themselves with board and room; our present students were so
lucky as to find room and board in Kelowna in exchange for a
little housework, but we hope that when the Kelowna Hospital
is enlarged, its nurses' home will be able to provide board and
room for our students. Laboratory aides, not laboratory technicians we are trying to educate. Our school is a school on trial.
We have two students who are working as aides in small hospitals. I have taken this opportunity to speak to you about
our school. We are willing to do all we can to train our students
as well as possible when we can find (forgive the word) a market for them. It is up to you to think this over, to talk over
with your doctors and with your hospital boards the urgent
need of a laboratory, the splendid help a laboratory could be
for diagnostic purposes. It is up to you to tell them that the
aides will have to do other work outside the laboratory, perhaps
it is up to you to find that work. It is with your help we hope
that our school will be helpful to the small hospitals of British
Columbia.
Upon motion the meeting adjourned.   12 noon.
At 12.15 a luncheon was held in the Hotel Vancouver, the
speaker being Dr. Alexander of Salt Lake City, Utah.
At 2.00 p.m. the Official Photograph of the Delegates was
taken on the steps of the Provincial Court House.
40 THURSDAY AFTERNOON SESSION
August 21, 1930
PRESIDING—Mr. J. H. McVety.
The afternoon session was called to order by the Presiding
Officer, Mr. J. H. McVety. Mr. C J. Cummings, Taeoma, Wash.,
Superintendent Taeoma General Hospital and President-elect of
Western Hospital Assciation, had been chosen to conduct this
Session. Unfortunately he was unable to be present so Mr. McVety agreed to conduct the same.
CHAIRMAN: Our first speaker at this Session is George
A. Greaves, M.D., CM., M.R.C.S., L.R.C.P., London, Director of
Physical Therapy Department, Vancouver General Hospital, who
will address this Convention on the question of
"THE VALUE of PHYSICAL THERAPY—ORGANIZATION
AND MANAGEMENT OF A DEPARTMENT
IN A HOSPITAL"
DR. GREAVES: The organization, management and value
of a physiotherapy department to a hospital — these questions
should all be considered by any hospital contemplating the development of a physiotherapy department and should be answered
before establishing such a section, as hospitals have their own
peculiarities in regard to the number and variety of their patients,
and the sources from which they originate, that is whether they
will be in-patients or out-patients, and also to the arrangements
or location of its wards. A careful analysis of these facts should
be made before setting out to establish such a department, and
the allotment of space, provision of equipment and staff should
be based on the finding of this examination. If this is not done
much time, money and energy may be wasted and much confusion
and inconvenience caused to those who will have to work in the
department.
In considering the type of department, it must first be decided what it shall contain, whether it will be a complete one,
that is whether it will be one prepared to do all branches of
the work included in the term physiotherapy, or whether it will
be one that will have only one or two of these branches represented. This will depend on the hospital. A general hospital
should have a complete department with all sections developed,
these include massage, occupational therapy, functional training,
remedial gymnastics, electricity, radiant heat, light both natural
and artificial, and hydrotherapy. Special hospitals, depending
on the type, will need one or more of these sections and the size
of the department or section will naturally depend on the amount
141 of work that will be referred to it, but it will be wise to give
consideration for probable growth, for a department of this kind
if properly managed will surely grow if permitted to do so.
When the hospital is housed in one building the department
will, of course, be in this building, but where the hospital consists of several buildings and at considerable distances from each
other as is the case with the Vancouver General Hospital, the
main department should be located at as central a point as possible in relation to the wards from which its work will be drawn,
this includes the out-patient department also. It could with
advantage be housed in a separate building connected by passages with the other units of the hospital. Separate, small departmental substations can with advantage be formed to cater to
the work of particular parts of the hospital. The main department should be on the ground level and have an easy and convenient approach for patients, both in- and out-patients, many
of whom though ambulatory are lame, and others have to attend
in wheelchairs or on stretchers. The department should have
plenty of light and air.
In most cases the location of a new department will be determined by the space not otherwise in use and its size will be
governed by the same factor, but even if the space available is
limited, it does not prevent the doing of considerable physiotherapy work.
The type and amount of equipment will depend upon the
circumstances already mentioned and one cannot positively state
just how much of any particular type is needed unless one is
informed of what will be required of it. Certain general statements may, however, be made. One air-cooled quartz lamp will
average to give three treatments an hour, a water-cooled quartz
lamp may treat fifty or more patients a day. A high frequency
machine will average three treatments every two hours. For
galvanic, faradie and sinusoidal machines it is difficult to be
definite. The types of cases treated by these machines differ
so greatly in extent that one is not safe to predict the number.
In addition to the equipment in the main department or its
substations, certain portable pieces should be available, or at
any rate some of the pieces in the department should be portable,
for use on the wards and in the operating theatres, for use on
patients who cannot be brought to the department, such as portable quartz lamps, diathermy machines, Bristow coils, etc. These
of course, should be controlled by the physiotherapy department
and be operated by its staff.    For special hospitals caring for
142 a limited variety of complaints the equipment problem is not
so great, as already mentioned one or two sections may be sufficient to look after the work.
Having decided on the type, size, location and equipment
■of the department, the next question will be its staff and organization. This is really the most important consideration, for
if the staff is not right the department will not function as
it should do, no matter where it is located or what equipment
it is furnished with.
In regard to the staff, this will depend again on the type
•of work which the department will be required to do and its
size. I will suppose that the department is to be a complete
one in a large hospital where the work referred to it will be
considerable and of diverse kinds. Such a department should
have as its direct head a medical man trained in this line of
work; if the department is not already in existence such a person should be consulted in regard to the factors already mentioned. The director should have had several years' experience
in the field of general work as well as being trained in physiotherapeutics. He will then be better able to utilize the facilities
at his command and be a better consultant than he otherwise
would be in the great variety of cases that he will be called upon
to treat. He should be able to compare the results of regular
medical and surgical methods of treatment of any condition
which is presented to him, with those to be obtained by physical
means, to know when physiotherapy will aid other treatment or
be superior to it. He must know the nature or pathology of these
conditions and as I have said before these are many, and the
effects of his physical forces upon them, and the wider his previous experience the more confidence the other members of the
staff and visiting doctors will have in his judgment. I do not
believe that this can be efficiently done by the new graduate
as recommended by some, particularly as to the last point, and
this is an important one. My experience was fairly wide when
I undertook to take up this special line and I have tried to
keep my knowledge of other branches up to date, but even so
I sometimes find myself in a tight corner. No physiotherapy
technician or operator can do this, or should be expected to be
able to do it. A lay technician should not have the privilege
of prescribing physical treatment any more than they have to
prescribe any other kind of treatment. Such persons when well
trained are able to administer a treatment designated by the
physician in charge and that should be all that is required of
them, though some doctors pay them the compliment of allowing
them to do this.   This is risky, it is no doubt often due to the
143 fact that there is no medical head to the department and because
some doctors do not know much about the physical forces used
in the department, and those that do lack the time to properly
supervise their treatments.
In many instances the director cannot take the initiative in
deciding which patients require treatment from his department,
but some arrangement should be made whereby he may visit
the wards and out-patient department with the attending staff
members and discuss with them cases where physiotherapy could
be used with advantage. This would be comparatively easy
of arrangement in closed hospitals where the staff have regular
days and hours of attendance and are not too numerous, but
in a large open hospital with hundreds of doctors visiting and
at irregular times it is impossible to do it. The director would
not have time for this, let alone do his other work.
It has been estimated that about half of the patients in a
general hospital would be benefitted by receiving some form of
physical treatment. I believe this estimate to be too low. It
will be part of the director's duty to inform the profession in
what way he can help them with the staff and equipment at
his disposal. The doctor in direct charge of the patient sould
issue the order for treatment and indicate if he will, the line
of treatment he desires given, but the details of its application
should be left to the director as a general rule.
There are occasionally special cases where the attending
doctor would like some particular line of treatment or technique
followed and the director should be willing to do this for him
if he can, but this must be the exception, for if every doctor
referring cases for treatment, specified the manner of its application, etc., we would have so many techniques that the work of
the department would be seriously hindered.
The director should see each patient for whom treatment is
ordered and become familiar with the condition present, and
then issue instructions to his staff for the carrying out of the
treatment, explaining the nature of the case to them. He should
supervise the treatments as often as possible and check up on
the progress, until the case is disposed of.
He should be supplied with clerical-assistance to look after
records, cash books, correspondence, etc., so that his time will
not be taken up with duties that can be more cheaply done by
others. A director of a large department is a busy person and
needs all his time for consultations with attending doctors, supervising his patients and operators, looking after his equipment
and a host of other things.   He should keep his superintendent
144 informed of the condition of his department and suggest improvements or changes in policy or equipment and be responsible for
the carrying out of any policy or arrangement ordered by the
superintendent. He should attend staff meetings of the hospital
and be prepared to discuss questions pertaining to the department. He should have control of the internal workings of his
department insofar as the staff, equipment, arrangement of rooms
etc., is concerned.
Besides the director and his office assistants, an adequate
number of operators acting under his direction are needed. The
number of these will vary, depending on) the type of work they
are required to perform. For example, one operator in a quartz
light section can supervise several lamps and dispose of thirty
to forty cases daily, whereas another who is giving massage may
only be able to treat ten to twelve daily (eight hours).
Each section of a large department should have at least
one fully trained technician and as many assistants as the work
requires. The assistants may be pupils, but from my experience
during the past few years with a training school for technicians
in connection with the department, the tendency is on account
of limited funds to limit the number of fully trained operators
and to use the pupils to do work which fully trained persons
should do. If pupils are accepted for training, little or no decrease in the number of trained staff should be permitted. The
pupils at first are a liability, they need almost continual supervision by other members of the staff, which should be increased
rather than decreased. It has been recommended that the pupils
in the nurses' training school should be given a short course in
the physiotherapy department during their training; I am not
in favor of this. It might work out to be practical where the
training school was very limited in numbers,-but where there
is a large school with two or three hundred pupils, I do not
think it is practicable. The number of nurses in each class
sent to the department would be more than could be absorbed
and it would necessitate increasing the regular staff to look
after them. At best these pupils would only be partially trained
and when they had left the hospital there is no doubt that they
would be used to do some of this type of work. I do not think
it is fair to permit partially trained persons to cut in on the
work of persons who have gone to the trouble of taking a complete course. We have, however, this year undertaken to give
the nurses in training a short course in massage consisting of
some sixteen lectures and demonstrations covering a limited
variety of conditions in which I agree with the Superintendent
of Nurses, that nurses should be able to attend to.   Nurses have
145 just about as much as they can digest in the full course given
them now without adding to it. I have no objection to a graduate nurse becoming a fully trained technician. In order to expedite the work of the department, I have found it better to divide
the main department into sections, such as quartz light, massage and functional training, high frequency, galvanic, faradie,
sinusoidal, etc., with each section having its own staff. Patients
requiring more than one variety of treatment pass from one section to the other usually. This may appear to have objectionable qualities and in a way it has, but with us at any rate it
has advantages which outweigh the disadvantages. The operators in each section become more expert and it avoids the confusion which occurs when each operator is permitted to start
and complete a mixed treatment, unless practically each operator
has a complete set of instruments, and if a training school for
technicians exists, it is easier to check up on what each has
done as they pass through the sections.
If such a department is established it will be found to be
of assistance to all the other services and its usefulness to these
will be in direct proportion to the completeness of the department and the competence of the staff. Services such as orthopedic, ear, eye, nose, throat, surgical, general medicine, maternity, neurological, skin, tuberculosis, genitourinary, all make use
of the department and to an ever increasing extent.
Physiotherapy is of value also because it can be shown that
where it is properly used on appropriate cases, their stay in the
hospital in many instances is shortened and in others though
their stay may not be reduced, their condition on discharge is
better than it would otherwise be.
Not only is the department profitable from the standpoint
of discharges and results, but also from a financial standpoint.
A department after it has enough equipment and staff should
pay its way and even yield a profit. Ours has done so. Our
department has not cost the hospital a cent, in fact the treasury
has been enriched by several thousand dollars from having had
the department. The amount of profit, of course, will depend
mostly on the class of patients treated — that is whether they
are pay or non-pay patients. Hospitals restricting their patients
to pay cases as some do, will have no difficulty in making a
large cash profit. In other cases, the profits will vary depending on the proportion of non-pay cases. Our treatment charges
are not high, our collection average about one-third of the booked
charges. This is not meant for a criticism of the collection service, it is due to the fact that we book all work done whether
146 pay or nOn-pay, and a large percentage of our work is non-pay.
About one-third of the work is contract.
To try to enumerate all the conditions in which physiotherapy
can effectively form a part, or in some instances the whole treatment, would be difficult as the list would include most conditions. I do not wish to imply that physiotherapy is a panacea
for all ills, but there are few where some branch of physical
treatment will not be found useful, in some, of course, to a
greater extent than in others. In a few it is sufficient in itself,
but mostly it must be looked upon as an adjunct to other rec-,
ognized methods of treatment. The use of physiotherapy does
not prevent the use of other methods in the majority of cases.,
In fact it is only when there is perfect co-operation between
the various services and the physiotherapy department that it
can perform to the best advantage. Once in a while it is best
to let physiotherapy act alone, but teamwork with the other
services is the rule.
CHAIRMAN:    Is there any discussion?
MISS HENNINGER: I would like to ask Dr. Greaves if
he has much out-of-hospital practice or is his service confined
to the patients in the hospital?
DR. GREAVES: We have about one-half out-patients coming from the city at large and one-third ward cases. Of the.
cases coming from outside, about one-third come from the clinic.
The physicians as a whole send in the remainder. We accept
ho cases that are not referred by the doctor in charge of the
case. Patients cannot walk into the hospital and receive treat-,
ment. We prefer to have the doctor give us a diagnosis of each
patient.
MISS HENNINGER: You would tell him that it would
be necessary to see his physician?
DR. GREAVES:   Yes, under the present circumstances.
MR. WITHERS: Has Dr. Greaves any solution of the
problem we are facing in our hospital in New Westminster, where
we are doing this work under the charge of a qualified technician. The medical staff admit themselves they do not know
anything about the machinery used in physical therapy and they
are leaving that work to the discretion of the technician in
charge of the department. How shall we overcome such a problem? We realize it is not as it should be, but is there any solution?
DR. GREAVES: In a hospital more or less limited in funds
you will experience that predicament. In my talk I gave you
147 what I felt would be the ideal state of affairs, but it is not always possible to reach the ideal. I know your department in
New Westminster, it is not extra large and it might be somewhat excessive to pay a medical man a fair salary to look after
that when he would not need all of his time there. You might
do what they are doing in St. Paul's Hospital and that is employ a part-time medical man to supervise it.
CHAIRMAN: I shall now call upon Miss Alice G. Hennin-
ger, R.N., Superintendent Pasadena Hospital, Pasadena, California, who will discuss the question of
"COMMUNITY RELATIONSHIPS OF A GENERAL
HOSPITAL—HOW DEVELOPED AND HOW
SUSTAINED"
MISS HENNINGER: Probably no institution makes a
greater contribution to the happiness and well-being of the community which it serves than the modern well-equipped hospital.
It is the refuge we seek when we are distressed physically. The
modern hospital is fully equipped and ready to serve in any
emergency. Because of the uncertainty of health and the increasing number of traffic accidents, no one of us knows but that
he may, at any instant, be very grateful for the service it offers.
The primary purpose of the hospital is the care of the sick but
in addition to this it has other important functions.
The hospital offers facilities for the training of the graduate
in medicine he could obtain in no other way. This training
makes it possible for the young physician to assume his proper
responsibility in the maintenance of community health.
Likewise in our hospitals young women are taught the proper
care of the sick and are then valuable factors in the promotion
of health.
The hospital is rapidly growing to be the health center of
a community. The clinic conducted for the poor of the community takes care of illness in its incipient stage and thus oftentimes prevents serious illness. By availing himself of the advantages of the clinic the bread-winner or home-maker of limited
means can many times pursue without interruption his tasks.
In the aggregate this is a tremendous economic saving to the
community. Patients are taught some of the fundamentals of
health and how to prevent their particular illness while in the
hospital or being treated in the out-patient department. More
recently hospitals have grasped their opportunities for preserving the health of the commiinity, i.e., preventing illness as well
as curing the patient.    To this end some of our hospitals are
148 sponsoring monthly lectures on health matters. Hospitals are
co-operating with the public health officers in making health
examinations. Some are co-operating in the giving of the various
prophalactic vaccines and in periods of epidemics many of our
hospitals have placed the facilities of their laboratories at the
disposal of public health officials. From the foregoing it will
be seen that many hospitals are serving their communities not
only by caring for those acutely ill, but also that they are vital
factors in all matters where health is an issue. Yet, notwithstanding the altruistic attitude of hospital administrators and
the great service that our hospitals are rendering in their respective communities, we hear of much lack of appreciation and
even of criticism from the publie. What are the factors that
have brought about the disaffection that exists in the minds of
the public ? It will be the purpose of this paper to discuss some
of the causes that have led to this lack of appreciation and to
suggest some measures by which understanding and goodwill may
be secured and sustained.
The Satisfied Patient—Without doubt the satisfied patient
is the best advertisement a hospital can have. If we would satisfy our patients we must give them comfortable, cheerful surroundings at a price that is within their ability to pay, good
nursing care, good food and good medical practice. If, added
to this, the personnel of the hospital has a definite interest in
the patients, the results will be happy indeed. Courtesy and a
sympathetic desire to promote the comfort of the patient bear
large dividends in the hospital. The patient takes it for granted
that the larger issues, namely, scientific medical and nursing
care and good food will be provided. Our hotels, departmental
stores and in fact all modern successful business institutions have
found that service, which is the keynote of happiness, is just
as essential to success. Large salaries are commanded by business executives who have studied and found ways to be of service in a superlative way, to their patrons. We can well profit
by their example in the attitude we assume toward our patients,
our staff and the community.
Ways of Contacting the Community — Probably the most
common cause of criticism is the lack of understanding of the
problems of the hospital and of its purpose. There are numerous
ways, beside contacts with patients, by which the hospital can
develop and sustain helpful contacts with the community.
1. The Board of Directors—The Board of Directors of the
hospital has a very definite responsibility in interpreting the
hospital to the public. The members of the Board should be representative citizens of the community, respected for their ability
149 and judgment and willing to make every reasonable effort for
the betterment of the institution. It is the duty and privilege
of the Superintendent to properly interpret the work and needs
of the institution to these members who in turn contact their
friends. Thus an appreciation of the worth and work of the
hospital is stimulated.
2. Local Press—One of the most powerful allies of the hospital in securing the proper relation with the community is the
support and co-operation of the local press. This support should
not be difficult to obtain because the interests of the newspaper
(to secure news) and that of the hospital (to get news properly
interpreted to the community) are so similar. A personal interview with the Editor of the paper will establish a mutual understanding. The paper is grateful for news that can be released
from the hospital and in turn the superintendent can keep his
community informed of what the hospital is doing and of its
need. There are human interest stories that it is possible occasionally to release and these are eagerly sought for by every
periodical. Certain of our hospital magazines are making it
possible for the hospital to publish monthly hospital news bulletins.    In many instances these are most helpful.
S. Observance of National Hospital Day—A valuable means
of establishing proper relationship with the community is through
the opportunities offered by the observance of National Hospital Day. So much has been written about the programmes for
this day that it will be sufficient to say that when members of
the community can be induced to actually visit the hospital and
learn of the constructive work being accomplished therein, their
criticism for the most part will be turned to praise. By all means
grasp the opportunities offered by National Hospital Day.
4. The Annual Report—The annual report is an excellent
means of apprising the community of the real problems and
achievements of the hospital. This report too frequently consists
chiefly of detailed medical and financial statistics which contain
little of interest to the laity. It should preferably relate, and
properly interpret in an interesting manner, the chief accomplishments of the year and indicate the methods by which further
progress can be made. If the community can be made to realize
that the hospital is theirs and that its sole purpose is to serve
their needs, it will stimulate pride of possession and a desire
on the part of the community to further the interests of the
hospital.
5. A Women's Auxiliary—In. all communities there exists
various women's clubs.   Many of the members of these clubs are
150 really satisfied only when they feel they are accomplishing something in a constructive way for others as well as having certain
social contacts. In a certain hospital in California, a group of
such women have formed a Women's Auxiliary of the Hospital.
They number about four hundred members and for their social
enjoyment they have three or four afternoon teas or receptions
during the year. Their business meetings are held once a month.
Money for the benefit of the hospital is raised by annual dues
and this is augmented by the proceeds from some form of entertainment or bazaar which is held annually. Money gained in
this way, augmented by voluntary contributions and voluntary
workers, makes this auxiliary a very real asset to the hospital —
not only in a financial way but in the promotion of friendships
for the hospital as well. Funds obtained by this organization
have been very useful in providing certain improvements and services that otherwise would have proved difficult for the hospital
to finance. Among the innumerable services provided by this
group we would mention the making and distribution of individual jellies for patients — the distribution of books and making of surgical supplies — redecorating and refurnishing the
Children's Ward — new inner-spring mattresses, for patients'
beds — electrically heated tray wagons —:the providing of
flower gardens and walks about the hospital. They have also
provided hospital funds for certain worthy cases and-have given,
funds for special nursing care where the need was indicated and
funds lacking. These and innumerable smaller services, to say
nothing of the moral support of such an organization^, makes it
a valuable ally in securing the proper relationship wjth the
community.. mo-«!   ] i!
6. The Out-Patient Department—The Dispensary or Outpatient department of the hospital serves the poor of the community, who even though ill are not bedfast.'' Many are able
to continue their work while treatments are being received. Almost without exception we find the best specialists' in medicine
connected with the hospital working in the Out-patient Department. The value of the constructive health work that the hospital is able to thus give to the community is incomparable. Undoubtedly as hospital administrators we do not stress the value
of this work to the community sufficiently. The expense incident to conducting the Out-patient Department is a community
responsibility and not a legitimate hospital expense if the hos-
pial is dependent upon the income received from patients for
its support.
7. The Social Worker— The social worker can be of great
value to the hospital in properly interpreting it to the commun-
151 ity. She not only contacts the patient at the bedside in a helpful and friendly manner, but meets his relatives and friends as
well. She many times can and does help him to solve his economic
problems. Through the work of her department the patient is
made to feel that the interest of the hospital extends beyond
his care while in the institution. Through her interest and skilled
efforts many a patient, who would without her assistance have
been a burden on the community, is returned to society independent and self-supporing. This is constructive work, the value
of which the community is not slow! to grasp and appreciate.
8. Other Organizations of the Community — The hospital
should at all times co-operate fully with the other welfare and
public health agencies. By conferring with these organizations
about borderline cases and by demonstrating a desire to co-operate with them in serving the community in all health matters, a
like spirit is engendered for the hospital.
9. Frank Statement of Costs —One of the most common
criticisms of the hospital is that charges are too high. We thoroughly agree with the public that the principles of business efficiency sould be adhered to and that the charges should be as
low as is consistent with efficient service. The public should be
informed as. to just what constitutes hospital costs and the reasons for the increase in costs during the past fifteen or twenty
years. If it can be clearly demonstrated (and it is possible) that
hospital charges have increased far less than have the cost of
labor and supplies upon which the hospital depends for its operation, much good will have been accomplished.
From this discussion it is plainly indicated that one of the
responsibilities of the Superintendent is to assist the hospital
and the communty to function smoothly. To accomplish this
there must be mutual understanding and confidence. It is desirable that the Superintendent make many personal contacts —
that he be interested to a degree in all matters that pertain to
the welfare of the community. While his greatest efforts will
always be needed within the institution itself, he must not neglect opportunities to interpret to others the work and problems
of the institution he serves.
It is now generally conceded that the community owes something in a financial way to the general hospital in its midst.
It seems reasonable that if the community establishes and supports its Police Department to preserve order, its Fire Department to protect the property of the citizens, it is only reasonable
to suppose it will do something to support the Hospital which
is the health centre of the community and has facilities for prolonging life and even saving life itself.
152 It is plainly evident then that a modern, up-to-date hospital
is a community asset and generally speaking, the higher the
type of hospital the wider the scope of its activities, the more
progressive the community will be found to be.
We have only mentioned a few of the many ways in which
a desirable relationship between the hospital and the community
can be developed and sustained. In summing up the importance
of these various factors in establishing proper relationship with
the community, I would stress the importance of the hospital as
a health centre. I believe in our intense desire to be of service
to the sick, we have overlooked the fact that the hospital can
offer through the means of the periodic health examination, lectures on health and various other activities, a service that can
be obtained in no other way. If we can get the community in
the habit of coming to the hospital for instruction in health
matters when they are well, we will have gained their confidence
and there is no doubt about where they will want to go when
they are ill.
If the Board, the Superintendent and the personnel of the
hospital is sincere in its effort to properly serve the community
and is alert to grasp opportunities for service as they arise, there
is no doubt but that the hospital will find itself facing an ever-
widening field of service and enjoying the confidence and support of the community.
CHAIRMAN: Is there any discussion on this very interesting paper?
(No Discussion)
CHAIRMAN: Libraries and Hospitals comes next and I
shall now call upon Miss Helen G. Stewart, Ph.D., New Westminster, B. C, Director of Carnegie Library Demonstration, to tell
us something about this. Dr. Stewart, who will discuss this subject of
"LIBRARIES AND HOSPITALS"
DR. STEWART: It is a little difficult to talk about libraries in a clear-cut, direct way because the idea of libraries has
become so sentimentalized in the past generation or two, that
before getting down to tacks, one must clear away a lot of sticky
sentiment and fog which surrounds it, and present it as a practical, not to say, urgent proposition.
People are so obsessed by the traditional values of books,
that their real place in modern civilization eludes them. The
clouds of glory trailing from the past, have a habit of completely
veiling the discrepancy between the funny little antiquated assort-
153 ments of odds and ends and left-overs, so often dignified by
the name of Libraries, and the reading needs of a modern community or institution.
Practically every hospital board in the country is willing
to admit on principle, that libraries have a place in their general scheme of things, because they have been brought up in
this belief. Yet those who are willing and able to translate that
principle into a concrete policy, and more especially to have
those policies sufficiently concrete to appear on their actual
budget as in the case of stenographic help, or laboratory equipment, are as hard to find as roses in snow drifts. Some few
books have been purchased but purchased for a specific purpose,
but when one realizes that in the whole of British Columbia,
and I am speaking of British Columbia in so far as the report of
the Library Survey Committee is concerned, when one realizes
that in the year 1926 the immense sum of $370 was expended
by all of the hospitals put together for books and periodicals
one can realize that as far as a purposeful policy is concerned,
we have a long distance to go. In this Province of British Columbia, according to a survey made in 1927-28, well over one-
third of the 41 hospitals, from which information was gathered,
reported that they had made no provision whatever for library
service. The rest maintained some sort of a collection, ranging
in size from 50 to 70 volumes, but only one found a place in
its regular budget for reading material. The total book stock
of 25 institutions fell short of 5000 volumes, and one gathers
from the Survey Report, that most of these have been accumulated in a casual fashion, through book drives and private philanthropy. I may say right here, that so far as my own knowledge goes, I do not think that British Columbia is very much
behind certain other parts of the world in that respect. The
trouble has been to a certain extent at least, that the world has
got ahead of us, and in relation to the professional hospital libraries, the little libraries that are now operating under that name,
are in many cases, more or less hang-overs from a distant past.
Boards and doctors and nurses have been so obsessed in the past
with the idea of the traditional values, that they have failed
utterly in many cases, to see the real value of the books and
the real necessity for the books in any modern scheme, which
a modern world demands from them. Just what these needs
are it is not quite so easy to say. Libraries up-to-date, in so far
as hospitals are concerned, have largely been desultory affairs,
largely casual. No mention was made in any of these reports of
librarianship, or of any adequate facilities for selection and organization.   Indeed no person seems to care enough about the
154 whole matter to keep any special record of what these collections
of books do to further the interests of the institution. Some
appear to be set aside for staff use, and to contain at least a
few works of purely professional interest. Some are earmarked
from the start for the patients. In most cases, and now I am
speaking with very little direct knowledge, but in most cases
the patients' library consists almost entirely of books which have
been donated in one way or another, generally by hospital auxiliaries or organizations of that kind. Most of the purchasing
which is done for the staff of the hospital is done having regard
to professional books, but as far as I can gather, even these
books are purchased in a more or less desultory fashion, without a very large knowledge of the whole field of professional
literature, or on the other hand, without any very technical use
of what we call the essential tools of selection and organization
for purchases of that kind. And while hospitals the world over,
with few exceptions, are in the same position as we are ourselves in this regard, the real urgent need for some definite plan
of library service in hospitals, as in certain other institutions,
becomes more and more acute every day. There is an immense
flow of books coming from the publishers which never seems
to end, hundreds, thousands, tens of thousands flowing out every
year, so that even the greatest expert cannot do.more than have
a nodding acquaintance with the outlying parts of her own particular field. With the constant flux and change which throws
yesterday's theories into the scrap heap, with the increasing
specialization of specialists and the increasing need for orientation and the expansion of community boundaries, some clearing
house of specialized information and knowledge becomes more
and more imperative.
Whether you realize it or not, the day of the vague, general, desultory library is over. What is coming to take its place
is an effective tool, shaped to the hand of its user. A modern
library is as much a matter of supply and demand as is a modern
departmental store, and it requires as much skill and subtlety
in its successful operation, which does not at all mean that it
must be put on a purely materialistic basis, but that its policies must be the results of conscious effort and the measure of
its achievement not merely a matter of wishful thinking. It
must be purposeful and focussed, adapted to the needs of a
special clientele and operated with as much knowledge of processes and techniques, as a laboratory is operated. It is a difficult thing to run a library on these lines. There is nothing
casual or desultory about it. It is an expert's job. It is especially difficult to organize such a service in small communities.
155 It needs a range and scope hard to attain except where there
are people and money. Isolated efforts or small units, however
much enthusiasm goes into them, are bound to fail, to become
stagnant pools or shallow marshes instead of swift flowing useful
streams. It is partly because hospital libraries have almost always been little isolated efforts that so many of them fail. I
know very little about hospital libraries and therefore I will
probably make a number of mistakes while here today because
hospital libraries are not a specialty of mine, but I will say this,
that because public libraries and other kinds of libraries are
going through about the same stage as hospital libraries are at
the present time, perhaps some of our own experiences may be
of a certain benefit to those of the rest of you who are fumbling
about for some way out of a difficult proposition.
My position at the present time is in connection with a
library experiment which is being tried out in the Fraser
Valley. This experiment is financed by the Carnegie Corporation from New York City, and the reason they are
giving money to finance this experiment is simply because the
library focus has so changed in the last number of years that
the old methods, which were adequate enough a generation ago,
have fallen down and failed. The new methods which are necessary in order to run a library, particularly in a district where
the population is more or less scattered, now demand a certain
type of focus without which almost any kind of library project
is doomed to failure. Now hospital libraries, like publie libraries
in rural communities, have up to the present been isolated units,
•cut off from their own kind. They have worked by themselves
and through themselves and for themselves and those who have
been responsible for them like "Elijah under the Juniper Bush"
have wrestled away with their own problems not knowing there
was any person else with the same problems or the same interest.
Both hospital libraries and public libraries in small communities are very likely to see in the near future a change very much
for the better through the use of these two ideas of focus and
federation, and it is along these lines that progress may be expected.
Before suggesting any of the practical ways, I think it might
be very well for one moment to discuss a little more fully what
the hospital libraries might do. What is their responsibility,
or what would they have to take into consideration in the way
of operation before any concrete plan was definitely adopted?
As we have said, the natural division at the present time seems
to be professional and patient, but each of these classes will
stand a little dividing.   As I see it, although I know very little
156 about hospitals, a hospital library has not only an opportunity,
but a definite responsibility for the supply of certain kinds of
reading needs. First in connection with the student nurses in
training. A hospital accepts students and exacts from them long
hours of service for a period of three years on the strength of
giving them a professional education, but they are not giving
them in return a good professional training. The craft part
of their training they can get probably well enough, in the way
all other apprentices do. But professional education demands
a knowledge of principle as well, and also an ability to think
creatively, and this cannot be imparted to the students without
a minimum supply at least of the tools of learning. There should
be a sufficient number of right up-to-date text books to give
various points of view on the actual subjects taught. There
should also be books giving the cultural background of these
subjects and their relation to other knowledge; material linking
up their professional specialty with the social environment in
which they must practise it, and finally a constant supply of
material to help their personal development during these years
of training. No school professing academic standards can do
less than this, in fairness to its students and to its own professional reputation.
No professional staff can grow and progress to-day if cut
off from the thought of their kind. Once responsibility for
such mental alertness rested with the individual, but to-day it
is far from being an individual matter. No big firm to-day would
dream of running a chemical laboratory, a patent office, a trust
company or an international banking concern without having
a highly effective library at the centre of their organization —
not only books, but hundreds of magazines selected and classified for the use of their busy and alert staff. It is only the professionals, once the centre of the reading tradition, who fail in
this regard, or strain their personal resources to the breaking
point to keep up with the demands upon them. Nurses and
doctors alike need service of this kind, and indeed without it,
cannot possibly hope to take the place expected of them in their
community. As in the case of the students, there is also the matter of a broad, cultural reading for the professional staff and
those who live an institutionalized life have a right to expect that
a part at least of these needs will be satisfied by the hospital
itself.
Then there is the question of reading for the patients. From
a standpoint of direct therapeutic value reading offers large
possibilities scarcely more than hinted at, at the present time.
Again my ignorance stands in the way of saying anything very
157 definite about these possibilities, but I am practically certain
that before many years pass it will be quite possible to make up
reading diets in the same way as one is able now to make up
regular food diets. It is altogether likely that normal reading
needs call for certain vitamin contents, certain calories, certain
salts and minerals, fluids and roughage, as much as diets do, only
no person knows enough about them yet to say what they are.
Certainly from a standpoint of suggestion and inspiration, from
a standpoint of purposeful study, from a standpoint of making
up shortages and satisfying hungers, books selected and organized and administered properly can do much for both the mind
and body of all but those who are very, very ill. But there
must be a conscious plan about it all.
There may be many other uses for a library but it seems to
me that a hospital library might very well be the professional
centre in any event for the reading matter for the whole nursing
and medical profession, and with certain limitations that is a
matter which could be worked out later. If one takes anything
like that view of hospital libraries, if one admits for a moment
that there is anything like that responsibility resting upon them
which I have stated—and it seems to me you cannot get away
from it—then the question arises how can a hospital library be
operated in such a way that it can fill some of these requirements? I have stated the isolated hospital libraries are almost
doomed to failure from the start. I think hospitals might see their
way clear to work out the same sort of scheme that is being tried
in the Fraser Valley experiment, that is in place of having little
libraries, one in Chilliwack, one in Mission, one in Abbotsford and
one in Haney, etc., the experiment is to pool resources and to pool
interests, and with these pooled resources to prepare a larger programme which can support a larger scope and range of books,
which can support a highly trained staff and which can give to
the readers in the Valley a number of books and a range of books
that would be absolutely impossible in any one of these isolated
library centres. There does not seem to me to be any reason
why, for example, the hospitals in British Columbia should not
federate under one large hospital library scheme by having one
large common stock of books arranged in this way. We have
a rural bus which carries the books from one branch to the
other. I do not see anything insuperable in the way of some
sort of regional depots which would make it possible and practicable, that is to have the minimum basic supply of books in
each of the hospitals and then a large common stock which would
keep rotating so that the hospitals would have the advantage of
having one highly trained staff which could operate the whole
158 thing, could organize, advise, help and classify. One supervising staff could supervise and arrange in the smaller hospitals where a trained librarian would be quite out of the question, and it would seem that your problem could be worked out
with the maximum of effect and with a minimum of cost. If
our present scheme in the Fraser Valley can be put through, it
will give every person in the Fraser Valley, no matter how far
away from the centres of population, by the end of the five-
year period, a choice of something in the neighborhood of 50,000
volumes, and I think we can do that at a total cost eventually
to the borrower of something like 30 cents per capita, which,
does not seem to me to be exorbitant. That includes a highly
trained staff and also includes the most up-to-date and best type
of library service which has been worked out up to the present
time.
If the hospitals in British Columbia are at all interested in
that sort* of thing, I would say that now is a very good time
when they can make that interest rather effective. This demonstration of which I have been speaking, is a demonstration which
is financed for a five-year period, and during that five-year period it is our business in the Fraser Valley to do everything in
our power to further the library interests in any field. A certain amount of work that should be done in the hospitals, is out
of our jurisdiction, that is the highly professional type, but what
we could do during this five-year demonstration, if the Hospital Association of British Columbia wish to take advantage
of it, is first of all to place at its disposal, the experiences
which we have had in the working out of our own problem,
secondly to help in the way of suggesting the lines of tools, etc.,
in selecting books, and I may say that is a very highly specialized type of work at the present time, and thirdly, since our territory lies in the Fraser Valley, it is also within our power to
set up within the Fraser Valley, a hospital project, just as we
intend to set up a school project and various special interest
projects, which we would work through on a regular laboratory
basis to the best of our ability. It seems to me if the hospital
would take advantage of this opportunity sufficiently to get their
plans made, that they would really reap a very great deal of
benefit from the generosity of the Carnegie Corporation. We
are working under it at the present time and there is no reason
why you should not benefit from it as well as the others.
I would think if the Hospital Association wish to do anything along that line, they should first of all form some kind of
a working organization within the Association which would in
the first place get a little more information about what actu-
159 ally exists in the hospital libraries to-day. No person knows very
much about it. No person knows what books are considered educational, or how they should be used. No person knows what the
real needs of the hospital community are, and that is something
that could be shown by a committee gathering that information
together. Then there is a great deal to be gained in the way
of researches that are available in the realm of professional
matter, hospitals are getting no benefit at all from such research. There could also be a good deal done in the way of
studying the actual needs of your hospitals. And then
after these things were done or while they were being done, a
definite scheme could be worked out whereby the assistance of
the Carnegie Corporation could be gained in the project of
which I speak. I may say as far as we are concerned, we would
give every assistance to any such Committee, and if there is
anything in our power by which we can help through this particular matter of specialized libraries for the hospitals, you may
call upon us for anything that comes within our legitimate field.
CHAIRMAN: The Committe from the B. C Hospitals' Association will attack vigorously the question which Dr. Stewart has so ably presented to us to-day. We will endeavor to
find ways and means of transferring some more of the Carnegie Foundation money to British Columbia Hospitals, and we are
most grateful to Dr. Stewart for) her promise of assistance.
CHAIRMAN: I shall now ask Miss Kathryn K. Meitzler,
Los Angeles, California, Superintendent New Cedars of Lebanon
Hospital, to address the convention on:
"SOME OF THE NEWER DEVELOPMENTS IN
HOSPITAL EQUIPMENT AND PROCEDURE"
MISS MEITZLER: The radical change in the habits and
customs of people throughout the world is not more pronounced
than are the construction, equipment and procedures of the
modern hospital; about all we have retained of former years
is our ideals, without which our hospitals would not exist. And
yet this transition period of about ten years has witnessed such
keen competition among the inventive minds that whatever progressive hospital one visits, one finds some outstanding feature.
In our new building, completed and opened three months
ago, I doubt if we have any equipment that some other one or
more institutions has not installed, but by assembling what we
believe to be the outstanding types, we are happy in the result,
but we know that those who build to-morrow will have newer
developments from which to choose.
The tragedies resulting from improper film storage caused
us much concern and expense, inasmuch as our original plans
160 and specifications were wholly unsatisfactory to us as well as
to the fire commissioners, and the space provided for film storage is now used for other purposes, and a detached, partially
submerged reinforced concrete vault has been built 30 feet from
the main building and has been approved by Los Angeles fire
commissioners.
The lighting facilities for major surgeries are many and there
are several of the suspended spot type on the market that I
know are very good, but my preference is that of the general
illuminating type, in the ceiling, with converging lens. A suspicion lurks in the minds of many that this type of light radiates
heat to an uncomfortable degree, but tests of six hours' duration show a maximum of 83° wall temperature and 86° at 3 feet
above the operating table, or where the head of the operator
may be in the line of the crossing of the rays of light. These
tests were made during the month of July inj Los Angeles when
the weather was more than mild.
That the efficiency of the medical staff may be stimulated
to the highest point, many conveniences have been provided —
a large comfortable lounge room; a consultation room on each
floor; a medical library adjacent to the Board of Trustees' Room
and the President's office, to which they both have access; a
comfortably-furnished room on the surgery floor, where they
may smoke while dictating their post-operative findings; a suite
of two rooms and bath for the obstetricians, who may catch a
wink of sleep while waiting for a difficult case, and a dining
room where they are encouraged to gather for their noonday
lunch. Our medical staff is limited to the various respective,
specialties in which they register.
The central food service, by means of an electric conveyor
of the ascending type, is proving entirely satisfactory. The food
is not cooled during transit in the shaft and 100 trays are served
in 14 minutes.
The tendency to equip the patients' room in such a way that
they may forget they are in a hospital has a most wonderful
reaction on the patient, and color that is cheering has a marked
psychological effect. Great care should be taken, however, that
harmony prevails in color schemes, and that the aesthetic is not
impracticable. Patients are not awakened in the morning before
7. Mattresses and all pads used on operating tables, stretchers,
etc., are now made of the inner spring construction to insure comfort. Radios and telephones have been installed in the rooms,
also the over-bed table, solidly supported on both sides of the bed,
is most convenient.
161 Our maternity floor is distinctly a post-partum floor, and
has two large nurseries, one with carts containing four basinettes
each, for the babies cared for by general duty nurses, and into
this nursery no special nurse may enter—the other nursery, of
similar size, with single basinettes, is for her use.
The anxiety of the young mothers, after the recent stories
of the mixing of babies, set us thinking for some method whereby
there might be a definite linking identification of each mother
and her child; we already use the name necklace, the patch of
adhesive on the shoulder and the footprint of the baby, and so
we tried putting the mother's thumb print on the certificate with
the baby's footprint, and we believe it wiU prove a happy and
easy method of banishing the fear of not getting one's own baby.
This seems only a gesture, but if it identifies criminals, why not
a mother?
Our nursing staff is composed of registered graduate nurses
and we have provided a home for them — very comfortable with
a bath between each two private rooms. The eight-hour schedule
has been adopted for the general duty nurse as well as the
private duty nurse, which practically means group nursing.
Our Out-patient Department is to be opened on October 1.
CHAIRMAN:    Is there any discussion?
(No Discussion)
ANNOUNCEMENTS
CHAIRMAN: In accordance with your instruction of yesterday, the following telegram Was sent to Miss Emily Love-
ridge, Good Samaritan Hospital, Portland, Oregon:
Vancouver, B. C,
August 21, 1930.
Joint meeting of Hospital Associations deeply regret
your inability to attend the luncheon given in your honor
to-day. Copies of your reminiscences were distributed by
Dr. MacEachern, who spoke in highly complimentary terms
of your wonderful service. Delegates send greetings and
best wishes for long and- pleasant vacation.
(Sgd.) JAMES H. McVETY,
President, B. C Hospitals Assn.
162 Later hi the convention the following reply was received
from Miss Loveridge:
Portland, Oregon,
August 22, 1930.
J. H. McVety, President,
B. C Hospitals Association in Convention,
Vancouver, B. C.
"Sorry not to be with you in body but am in spirit.
Greatly appreciate your thinking of me.   Greetings to all."
(Sgd.) EMILY L. LOVERIDGE.
CHAIRMAN: The following communications have been received : A letter from Dr. Pearse, Superintendent of the Provincial Royal Jubilee Hospital, Victoria, regretting his inability to
be present at the convention as he was leaving on a trip to
Australia; and letters from Dr. C G. Parnall, President, and from
Dr. B. W. Caldwell, Executive Secretary of the American Hospital Association, regretting that owing to pressure of work they
could not attend the convention.
These communications were ordered to be filed.
CHAIRMAN
charge of the
I shall now call upon Dr. MacEachern to take
"QUESTION BOX"
CHAIRMAN:   Dr. M. T. MacEachern.
Q.—When there is a doctors' roster, should the hospital assume any responsibility for calls for the man who does not register "in"?.
A.—MR. OLSON: I would not do it in my hospital. If
a doctor did not register I would treat him as an absentee.
MISS MEITZLER: All of our doctors register. We have a
device whereby if a message comes in for a doctor say at 7 o'clock
in the morning, there is a little bulls' eye turned on against his
name. It is operated from the office and if the doctor does not
come in until 2 o'clock, it remains there until he does come in.
Q.—In computing the ratio of personnel to patients, is the
name of every individual (laundry assistant, engineer, etc.) whose
name appears on the payroll counted?
A,—MR. OLSON: Yes, also those not on the payroll, such
as internes, student nurses and student dietitians, we include them
all.
Q.—Should a hospital that is without an organized staff,
the latter having no rules and keeping no records, maintain a
training school for nurses?
A.—GENERAL:   No.
163 Q.—How can the hospitals secure a fair deal in the collection of hospital charges, in cases cared for under the Workmen's
Compensation Act?
A.—MR. McVETY: This question has been recently put
up by the Board of the Vancouver General Hospital to its counsel; after canvassing the situation thoroughly he has concluded
that the only way to clear up that situation is by an amendment
to the Act. The Executive Committee of the Hospital Association
will consider that legal opinion.
Q.—Considering the benefit the doctor receives from the
facilities provided by the Hospital, should not some of the ever
mounting cost of maintaining hospitals be defrayed by a levy
(of perhaps $200 per year) on each doctor admitting patients
to the institution?
MR. McVETY: No matter what the system is, the patient
would pay for it in the last analysis. If you impose a charge of
$200 on the doctor, you might just as well charge it to the patient
in the first instance.
MR. OLSON: The doctor should not be allowed to discharge
his obligation to the hospital by the payment of any money. He
should continue to work for the hospital and promote its- best
development and support it at all times.
Q.—Should patients be awakened early in morning, from a
sound sleep, to be prepared for breakfast and for the doctor's
visit?
A.—MISS DAVIS: I do not think it is necessary, I never
awaken a patient until after seven o'clock. If you awaken the
patient before that time, it does not make any difference; the
nurse knows the work has to be done, and after seven, she does
it in that much less time.
DR. MacEACHERN: I think there is a happy medium which
could well be followed.
Q.—How can the Matron of a hospital (where there is no
Medical Superintendent) obtain proper medical case records
where the doctors refuse to write histories unless a stenographer
is provided (which the Board considers impossible) ?
A.—DR. McTAVISH: The doctor always takes the history
in our hospital.   I think they should do so.
DR. MACEACHERN: It should be understood that it is
the obligation of every doctor to see that the record is kept.
MR. McGREGOR: If we have a doctor who does not keep
records, we report him to the consulting staff to deal with Km,
164 and if they cannot do so, then the Board deals with him and then
he is out of the hospital and we have no more trouble with him.
Q.—Should student nurses be placed on special duty with
private patients, and the hospital make a charge for such service?
A.—MISS RANDAL:   No.
DR. MACEACHERN: They are doing it in Canada and in
the United States. And do you know who is fighting it? The
doctors say that the engaging of student nurses for special cases,
while they do it very well, still is not fair to the graduate nurses,
and also the cost is not much less to the patient. That is a reason for some of your unemployment.
SISTER MILDRED: I would say that there should be no
charge at all.
Q.—Should the Superintendent attend all Board and Staff
meetings?
A.—GENERAL j   Yes.
Q.—Should regular conferences be arranged for the graduate nursing staff, and what should be the nature of such meetings?
A.—MR. G. W. OLSON: Yes, in our hospital the nurses
meet separately and they discuss all the problems that have arisen
during the previous week. They meet every Monday at noon.
MISS FAIRLEY: We have them every fortnight and we
discuss common errors. Just recently as there are so many
rapidly increasing changes in the X-ray and other special departments we have invited the specialists or the head of these
various departments to speak for 10 or 15 minutes, bringing out
the practical nursing points he has found lacking and we have
found these meetings very helpful.
Q.—Should a nurse be deprived of her regular "off duty"
hours as a punishment of neglect of duty, disobedience, etc.?
A.—GENERAL:   No.
Q.—Who makes the best Superintendent for a hospital —
a doctor, nurse or layman?
A.—MR. McVETY: It depends upon personality and administrative ability and also upon the size and type of hospital.
DR. MACEACHERN: I can look at this group and can
see the best of the three types, and you can in almost any group.
Some of our most efficient Superintendents on this continent
are laymen. Some of our most efficient Superintendents are
nurses; I can point to scores of women who are running hospit-
165 als today just as well as any person in the world. Most of our
Medical Superintendents are high grade, excellent men, some
of them not so .good; but any one of the three will do as long
as they have the personal qualifications and administrative or
executive ability.
MR. OLSON: As you know there has been a tendency for a
coterie of medical men to try to make it a law that the administration of hospitals should be entirely in the hands of the medical profession. That method is to be tried out very soon in the
Municipal Hospitals in the United States and laymen will be
practically precluded by ordinance from running these hospitals. I think that is unfortunate, but we are not in a position to fight it.
DR. MOOTS: It is just a question of the personality of the
individual and this is represented in the three types.
Q.—Should student nurses be present at doctors' clinical
meetings.
A.—GENERAL:   No.
Q.—Should a doctor give orders to a nurse in the presence
of the patient?
A.—MISS JACKSON: I do not think it is wise, because
in a great many cases it puts the nurse in an unfair position
and encourages a feeling of lack of confidence.
MISS FAIRLEY: The ideal way is for the doctors to write
their orders and not discuss them before the patient, but that is
not done. I think the medical profession should help us out by
urging the University Schools of Medicine to place greater emphasis upon the course in ethics and so improve the young doctor's attitude towards the hospital. These little things, or their
lack, we find make co-operation a little difficult.
Q.—How many hospitals represented have Medical Social
Workers ?
A. (By a showing of hands)—Five.
Q.—Do you find a profitable use for them?
A.—MR. —: Yes, we could not get along without them,
only wish we could employ more.
Q.—Should food trays be presented to the patient by the
maids or by a nurse?
A.—MISS —: By the nurses.
MISS RANDAL: I see no objection whatever to the maid
doing that.
166 MISS PIPES: A large majority of the private patients have
no objection, if there is a careful selection of the maids I do not
see why there should be any objection.
MISS SMITH: I do not think the maid is capable of looking after the patient in a comfortable manner.
MR. OLSON: It depends upon the size of the hospital and
the number of patients. We find it economical to have a Filipino
carry the trays and for the nurses to prepare the patient.
Q.—How can we protect the graduate from a small school
which has no Alumnae Association? The graduate of this school
finds a difficulty in joining nursing clubs, registeries, etc., has
her school no responsibility?
A.—MISS FAIRLEY: I would suggest in any hospital maintaining a training school, that the graduates of that school should
urge the formation of an Alumnae Association.
Q.—Why not abolish all Training Schools in Hospitals of
less than 150 or 200 beds, and staff the hospitals with graduates,
thereby relieving the unemployment situation and at the same
time ensuring a supply of well-trained nurses?
A.—MISS RANDAL:   I think that was covered yesterday.
MR. OLSON: Is there not actually a trend in the direction
in which this question points, that the number of training schools
throughout America is being reduced, rather than being increased
and also that the number of students in these schools is being
reduced. Could anyone answer that question. I believe there
is a trend toward the reduction of the number of schools as well
as the students enrolled in them.
MISS FAIRLEY: The Canadian Nursing Association sent
out letters urging the reduction of the number of students in
training schools and an increase in the number of graduate
nurses, hoping thus to improve the unemployment situation,
which they feel is somewhat permanent.
MISS RANDAL: I think automatically a very great many
of the training schools will go out of existence.
MR. WITHERS: Is there any institution represented here,
that is a fairly large institution, that has been operating a training school which has now a graduate staff ? If so, could they tell
us something of the comparative efficiency and comparative
economy?
MR. GLEN:   We would not go back to a training school.
MR.  : It is more   expensive   with   a   graduate   staff
but it is more satisfactory.
167 DR. MacEACHERN: If you are really trying to run a
good school it might cost you a little more.
MISS GRAY: Are there any large hospitals (of over 100
beds) represented here, that have reverted to the graduate staff?
(Show of hands requested)—None.
MR. FOLEY: Hollywood Hospital has 250 beds. They,
discontinued their school and are using graduate nurses. It
might be interesting for you to know that recently a questionnaire was sent out to the accredited schools in the United States
ane one of the questions asked was "Do you contemplate enlarging your nurses' residence?" Up to a short time ago, 300 replies were received and more than 70 hospitals and schools reported that they were enlarging their schools or putting up new
buildings and a number of others expressed a great need for
larger residences. I am offering this as a partial answer to this
question.
DR. MOOTS: It is only the small training school that does
not give the professional training that thinks it is economicaL
They run their training schools for economical reasons. The
professional schools mean an economic load.
Q.—How can the unemployment situation be relieved?
A.—DR. MacEACHERN: Is it not possible for nurses to get
a greater demand for their services if there were more mass
or group nursing? I find in the city of Chicago that perhaps
50 per cent, or more of the work is done by the nurse who is
not a graduate. The practical nurses are taken instead of graduate nurses and my own profession is to blame for the most of it.
The work is there, but it is being done by some person: else. It
seems to me we should create the demand for graduate nurses
by some co-operative scheme by which more people can take the
commodity, in just the same manner as your chain store.
MISS B. SMITH: Graduate nurses do not wish to go out
to do a great deal of the work in a house. They cannot adapt
themselves to the homes of small means.
MR. McGREGOR: Is it not a fact that the general public
do not feel they can afford to have a graduate nurse f
DR. MacEACHERN: If they could share their services,
the doctors should be able to get a graduate nurse for two or
three hours in a home and should be able to get that nursing
at a very nominal fee.
MISS SWOPE: I do not believe any system of making the
graduate nurse more valuable can possibly help the situation
unless our schools are reduced in the number of students.   In
168 Los Angeles city alone, a survey which was made about a year
ago, showed that there is a monthly average of about 2700
calls for graduate nurses. The doctor has his list of nurses and
some calls may be made by the hospitals. About the same time
a survey of the commercial agencies showed that about 60 nurses
per month were being called. This represented practical and
graduate nurses. I think the practical nurse remains longer with
her patient because she goes out and will do everything some
times, but at the same time we find that she charges $6 or $7
or $8 or $9 a day and often is not doing any more housework
than the grauate registered nurse does. While she does not
object to fixing up the patient's tray, etc., the registered
nurse does not feel that she should go into the home and take
the responsibility of the home in addition to the care of the
patient, except for an emergency period.
DR. MacEACHERN: I am making the appeal for you
to carry the nursing load. You have in the U. S. 120,000,000
people and a group of about 20,000 nurses. There is a
potential nursing load somewhere, but apparently the nurses are
not carrying it. We have heard a lot about the training schools
turning out too many nurses and about the unemployment
amongst the graduate nurses, but I do not think we realize how
much nursing is done in the United States and in Canada and
who is doing it. There are the two aspects — we know the
nursing load but who is doing the actual nursing? The figures
do not tally.   Who is doing this work?
DR. WARNER: Is it not a fact that you cannot get the
graduate nurses to go into the smaller centres? They like to
stay in the cities. I know in several instances we have canvassed
the situation and we could not get any one willing to go into
the smaller hospitals. I think a better distribution of nurses
would help the congestion somewhat.
MISS
That is a point I was going to bring up. We
sent to Winnipeg for a graduate nurse and were absolutely refused, they would not go into the country and they did not even
inquire as to whether there was a maid to do the housework.
MISS SMITH: We had a call the other day for a nurse to
be sent out to the country for an obstetrical case.. I called up
thirteen nurses and was refused by all of them, so I simply called
up a practical nurse and sent her out.
CHAIRMAN: It is time for this meeting to adjourn and
there are still many questions. Is it your wish to continue the
Question Box tomorrow at 9 a.m.   Yes (General agreement).
The meeting adjourned, 5 p.m.
169 FRIDAY MORNING SESSION
August 22nd, 1930
"QUESTION BOX"
CHAIRMAN: Dr. M. T. MacEachern.
The Question Box Discussion presided over by Dr. M. T.
MacEachern, was continued at the morning session.
CHAIRMAN: We shall now continue our further discussions
on these questions.
Q.—How can you limit the number of visitors in the hospital?
A.—MISS PHELPS: We have a printed leaflet which we give
to the parents of the children in our hospital, giving the hours
for visiting and explaining our reasons for limiting visitors and
we have very little trouble.
MISS HAWK: The Editor of our daily paper became seriously ill and was operated upon in our hospital, and while he
was there his employees came to see him and he became desperately ill again. When he recovered and left the hospital he
wrote a two column article concerning visiting in hospitals, and
once a month we prepare material to help him in editing another
column and it is a very wonderful help.
MR. MARSHALL: I think visitors should be admitted whenever it is convenient and does not disturb the patients too much.
MR. OLSON: It is extremely difficult to restrict visiting.
We ascertain the patient's wishes and try to carry them out.
DR. SEYMOUR: It all depends upon the hospital. If it
comprises large wards I think the visiting hour restrictions have
to be fairly severe.
MISS GREEN: Do you think it is advisable to have a
fixed rule? It seems to me we must use our judgment in almost
every instance. It is well to have some definite plan but you will
find it is necessary to vary that plan almost every day.
DR. SEYMOUR: In the Vancouver General Hospital we
have the visiting hours in the private wards from 10) to 12; 2
to 5 and 7 to 9; in the public wards 2.30 to 3.30 and 7 to 8.
Visitors are not permitted at other hours except by permit for
special reasons.
Q.—Should patients be allowed to smoke in public wards
at any time or only at stated periods?
A.—MISS JACKSON \ We have a rule whereby the patients
are allowed to smoke between 7 a.m. and 9 p.m. but not during
the night.
170 MISS DAVIS: We have a rule that they shall not smoke
during the night but the doctors come in and tell them they
may smoke.
MISS HENNINGER: We have a rule that the patients may
smoke from 7 a.m. until 8.30 p.m. but that does not apply to
women on account of so many objections from other patients in
the wards.
MISS FAIRLEY: We would like to know who should clear
up after they have been smoking. I do not think they realize
just what it means.
DR. MacEACHERN: The best thing would be to have a
smoking room on the floor for those patients who are able to
go there. It is the safest thing in the long run. The other
method is prescribed hours if you can carry it out.
MR. SLAYBACK: I do not think it should be allowed in
the open ward.
MISS RANDAL: I know there are a number of men who
do not smoke and I do not think it should be allowed.
MR. OLSON: I would like to know what to do about nurses
smoking.
DR. MacEACHERN: I say you should not allow it, when
you have nurses smoking you cannot get away from the odor
and it is disgusting to the patients. I have had two or three
complaints from hospitals in that respect. I am looking at it
entirely from the standpoint of the patient. The ethical and
moral attitude is a question for each individual to decide.
Q.—Has the Superintendent of Nurses a right to dismiss students without the sanction of the Superintendent of the Hospital?
A.—MR. McVETY: It depends upon the Superintendent
of Nurses.
MISS RANDAL: I think she would be very indiscreet to
do so. She should put her case clearly before the Superintendent
and in that way she is very much stronger as she needs all of
the backing she can get.
MR. OLSON: I think every Superintendent of Nurses should
report to her Superintendent any infraction of the rules on the
part of the student nurses.
MISS GREEN: Who employs the nurses, the Superintedent
of Nurses or the Superintendent ?
MISS RANDAL1:   Is a student nurse an employee?
171 MR. OLSON: The student nurse is selected by a committee
of which the Superintendent of the Hospital is a member. I
think, therefore, the student should not be dismissed by the
Superintendent of Nurses.
DR. MacEACHERN: The Board accepts the student nurse
through the Superintendent of Nurses.
MISS GRAY: Is there not a danger of taking away too
much of the authority of your Superintendent of Nurses? Do
you limit your Chief Engineer in his authority over those who
are responsible to him for the care of the heating plant? Is the
authority of the Superintendent of the hospital limited? Is he
not allowed a certain leeway to take summary action? The
Superintendent of Nurses should certainly have authority to suspend a student; her recommendation to discharge a student
should be presented to the Board only after careful thought —
and her recommendation should have weight. The responsibilities of a Superintendent of Nurses are very heavy, and she requires all the support possible.
DR. MacEACHERN: She is responsible for the nursing.
If you say she cannot suspend a pupil nurse, you put her in a
rather difficult position at times; I would say that no Superintendent of Nurses should dismiss a student without reporting
the action she wishes to take to her Board, but I certainly think
she should have the power of suspension. I believe that where
there is a training school committee, there is just the possibility
of that committee very seriously interfering with the authority
of the Superintendent of Nurses.
MR. OLSON: She should have the right to suspend immediately upon the discovery of any infraction of the rules, but she
should report the same to the Superintendent to determine how
long that suspension should be and whether it should ultimately
end in complete dismissal. In the final analysis the Superintendent of the Hospital should be the judge as to what is best
and what is not best in the hospital as far as the dismissal of
any of its employees is concerned.
MISS RANDAL: I do not believe that the matter of receiving students into the training school should be left to the
Board. I believe that should be left to the woman they have
appointed as Superintendent of Nurses, the woman who is specially qualified and trained for that very thing. Very often if
it is left to the Board, there is pressure brought to bear upon
that Superintendent of Nurses to admit some person into the
school who is not fitted for the work. My opinion is that the
Superintendent of Nurses should have the privilege of deciding
who should enter the school
172 MR. McVETY: H these young women get the opinion that
before a Superintendent of Nurses can exercise any major decisions she has to take the question up with some person else,
then her authority is weakened. I think she should as a matter
of policy, take the matter up with the Superintendent, but I
would hesitate to do anything that would weaken her authority.
I feel though that all employees should know that if any serious
action is taken an appeal may be made to the General Superintendent or the Board, but such an appeal should very rarely require any readjustment. I know in the Vancouver General Hospital where the discipline of nurses has come before the Board of
Directors, that it is an invariable rule that no name should be
mentioned and the decision is made purely on facts as submitted.
I hesitate to weaken the authority of the Superintendent of
Nurses.
MR. McGREGOR: The question of the dismissal of pupil
nurses is a very difficult one. I have noted that Hospital Boards
have been sued for the dismissal of pupil nurses. I do not
think anything should be done to destroy the morale of the
school, but when it comes to dismissal I think the Superintendent
of Nurses should consult the Superintendent and also the Board
of Directors.
MISS HENNINGER: We must remember that the student
has entered for a three-year course and while we grant the
Superintendent of Nurses all wisdom in the matter of the entering and discharging of students, the discharging of that student
is a very serious thing and has its legal and moral aspect. I
do not believe any Superintendent of Nurses should have the
right to suspend a pupil nurse after a five minutes' discussion,
her decision should be reserved until a little later. I think she
is well advised to take a little time to think it over and discuss
it with the Superintendent of the Hospital inasmuch as the hospital itself may be concerned in a legal aspect of the case.
Q.—Should the student nurse be permitted to take the scrub
at a major operation and alone?
A.—Miss Swope, Miss Randal and Dr. MacEeachern took part
in the discussion. There was agreement in the opinion that the
student must be carefully instructed in the technique and that
supervision of her scrub up work should be exercised as fully as
possible.
Q.—Has a hospital Board of Trustees the right to say whether or not a doctor may work therein?
MR. McVETY: I say yes, the Board has a right to say
what doctors shall be permitted to carry on a certain work.
MR. McGREGOR:   All hospitals are not incorporated under
173 the same Act. Some hospitals have a private incorporation. In
our hospital at Victoria we have absolute control and we can
keep out any person we wish to. Our Board has the sole right
to exclude any person from the hospital if it wishes to do so.
As the time was getting short, it was decided that no more
of the questions could be answered. Dr. MacEachern made the
suggestion, that in view of the great popularity of the Question
Box, that it might be advisable to have more time allotted to
this part of the programme at the next convention of the Western Hospital Association to be held in Oakland.
GENERAL SESSION
Moved by MR. MARSHALL seconded by MISS PHELPS
and carried "That the meeting be continued as a joint meeting
and that the portion of the business that is of primary interest
to each Association be dealt with in the general meeting."
(Motion Carried)
PRESIDING: Mr. G. W. Olson.
The Chairman then called upon Mr. McCulloch, convener
of the Resolutions Committee to present his report.
Mr. McCulloch presented the following resolutions which
were discussed singly as presented:
Moved by MR. R. C. McCULLOCH, seconded by MR. E. S.
WITHERS, "THAT this Convention of the B. C Hospitals'
Association express its approval of the recent revision of the Customs Tariff Regulations of Canada, permitting the free entry of
hospital equipment into Canada, and express the hope that, in any
contemplated revision of the Tariff, no increase in the duty on
such articles or supplies be effected; and that a copy of this resolution be forwarded to the Minister of Customs."
(Motion Carried)
Moved by MR. R. C McCulloch, seconded by MR. GEORGE
HADDON, "THAT WHEREAS the present regulations governing the inspection of meat and meat food products in Canada only
aPPly to such products as are intended for export purposes, which
include the inter-provincial trade;
AND WHEREAS in the interests of human health such inspection should extend to all meat and meat food products
offered for sale within this Province;
BE IT RESOLVED THAT this Convention respectfully request the Government of the Province of British Columbia to
enact such legislation as would ensure the proper inspection of
all meat and meat food products offered for sale in tihis province."
(Motion Carried)
174 Moved by MR. E. S. WITHERS, seconded by MISS MABEL
F. GRAY, "THAT inasmuch as the Hospitals of the Province and
the members of Hospital Boards personally, are responsible for
the professional care of patients; AND inasmuch as careful history-taking is essential to correct diagnosis, and careful record of
the course of the treatment is frequently essential in case of later
illness; AND inasmuch as it is believed that many hospitals are
remiss in the matter of records;
BE IT RESOLVED THAT the combined Associations (The
British Columbia Hospitals' Association, the Western Hospital
Association and the Northwest Hospital Association) in Convention assembled on the 22nd day of August, 1930, remind the
Hospital Boards of their responsibility and urge the physicians,
through their Medical Boards, to look into the subject of records,
and that the Hospital management co-operate in every way possible, bearing in mind that the physician is primarily responsible
for the completion of the clinical record."
(Motion Carried)
Moved by MR. G. W. OLSON, seconded by MR. BUCK,
"THAT WHEREAS hospitals everywhere perform a most vital
service to their respective communities, and especially in the
case of the non-profit hospitals, relieve the taxpayers of a large
share of the burden of caring for the sick and injured;
AND WHEREAS this service of these hospitals has been
recognized by forty-five States in the Union through laws granting exemption from general taxation;
AND WHEREAS the non-profit hospitals in the State of
California, who heretofore have not enjoyed any relief from
taxation, have instituted a movement to secure similar recognition of their services to the community and are at the present
time engaged in an intensive campaign for the adoption by the
voters of California at the State election next November of an
amendment to the State Constitution providing for tax exemption of non-profit hospitals;
THEREFORE BE IT RESOLVED that the Western Hospital
Association, in annual convention assembled, expresses its conviction that the policy of the great majority of States towards
their hospitals in granting tax relief is just and ought to be followed by all the States, and we particularly voice our support of
the movement of the non-profit hospital of California to secure
tax relief, and earnestly commend to the voters of California the
proposition known as Constitutional Amendment No. 6, on their
State Ballot at the general election November 4th, 1930, and
175 urge its adoption by a large vote as a deserved recognition of
the great public service of their hospitals."
(Motion Carried)
Moved by MR. R. C McCULLOCH, secondedl by MR. G. W.
OLSON, "THAT the thanks of this Convention be extended to:
The Province of British Columbia, the City of Vancouver, Messrs.
Buttar & Chiene, Auditors, to the Management of the Hotel Vancouver, to the Press; to all those who in any way contributed to
the programme of the Convention; to Mr. George Haddon for his
untiring efforts and practical assistance in the preparation of
the programme, and in arranging the details of this Convention,
which have so largely contributed to its success;
ALSO to the Provincial Mental Hospital, the Provincial
Sanatorium and to Doctor G. A. Ootmar for their splendid exhibits and helpful assistance at this convention,
AND ALSO to the Exhibitors of hospital supplies and equip
ment.
(Motion Carried)
Moved by MR. R. C McCULLOCH, seconded by MR. G. W.
OLSON, "THAT the thanks of this Convention be extended to
Doctor M. T. MacEachern for his attendance at this Convention,
and for the splendid assistance rendered by him in the preparation of the programme, and for his helpful and illuminating contributions to the proceedings of the Convention."
(Motion Carried)
Moved by MR. R. C McCULLOCH, seconded by Dr. R.
WARNER, "THAT this Convention go on record as expressing
regret that Dr. F. C Bell, owing to ill health, was unable to
attend the proceedings of the Convention, and to express the
hope that in the very near future he may be restored to health,
and that we may be privileged to have him with us again in our
deliberations when this Convention reconvenes next year."
(Motion Carried)
Moved by MR. G. W. MARSHALL, seconded by MR.
GEORGE McGREGOR, "THAT the report of the Resolutions
Committee be adopted as a whole and that the committee be
discharged."
(Motion Carried)
The meeting then resolved itself into a session of the Western Hospital Association.
176 BUSINESS SESSION
WESTERN HOSPITAL ASSOCIATION
PRESIDING: Mr. G. W. Olson.
The Annual Report of the Western Hospital Association was
read by the Secretary, Miss Phelps (Portland) and upon motion
her report was adopted.
(Motion Carried)
The Annual Report of the Treasurer was also read and it
was moved that the report be accepted subject to the audit and
final adoption by the Executive Committee.
(Motion Carried)
The Presiding Officer read a telegram from Mr.'.C.J. Cum-
mings, President Elect, who stated that owing to pressure of
work he would be unable to act as President of the Association.
Moved by DR. WARNER, seconded by DR. MACEACHERN,
"THAT the resignation of Mr. Cummings be accepted with regret."
(Motion Carried)
Moved by MISS CAROLYN E. DAVIS, seconded by REV.
AXEL GREEN, "THAT Miss Emily L. Loveridge be appointed
Honorary Vice-President of the Western Hospital Association
for life."
(Motion Carried)
It was decided that the office of President-Eleet be dispensed with.
It was also decided that the President be instructed and
authorized to appoint a Committee on Constitution and By-Laws,
with a view to bringing in a report at the next meeting.
Moved by DR. MacEACHERN, seconded by DR.! WARNER,
"THAT the Convention of 1931 be held at Oakland, California."
(Motion Carried)
It was decided that the time of the Convention should be
set later by the Executive Committee.
Moved by DR. WARNER, seconded by MISS SWOPE,
THAT the Western Hospital Review be designated the official
organ of the Association.
(Motion Carried)
Moved by MR. McCULLOCH, seconded by MR. BUCK,
"THAT the matter of publishing the proceedings be left in the
hands of the B. C Hospitals' Association Executive Committee."
(Motion Carried)
177 The following officers were elected for the ensuing year:
Honorary President: MALCOLM T. MacEACHERN, M.D., CM., D.Sc,
Chicago, '> __sociat»~_»irector, American College or Surgeons and Director of Hospital Activities,
Honorary Vice-President: EMILY L. LOVERIDGE, R.N., Superintendent
Emeritus Good Samaritan Hospital, Portland, Oregon.
President:.G. W. OLSON, Superintendent, California Hospital, Los Angeles,
.California.
First Vice-President: J. H. McVETY, President, British Columbia Hospital Association, Vancouver, B. C.
Second Vice-President: HOWARD H. JOHNSON, M.D., F.A.C.S., Superintendent^, St. Luke's Hospital, San Francisco, California.
Third Vice-President: ALICE G. HENNINGER, R.N., Superintendent,
Pasadena  Hospital,  Pasadena,  California.
Secretary: GRACE PHELPS, R.N., Superintendent, Doernbecher Memorial
Hospital  for  Children, Portland,  Oregon.
Treasurer: ELLARD L. SLACK, Superintendent, Samuel Merritt Hospital,
Oakland, California.; \4|
JO A'.Si' i '■• DIRECTORS
MRS.  LOLA      M.  ARMSTRONG,  Editor Western  Hospital  Review, Loa
Angeles, California.
R. D. BRISBANE, Superintendent Sutter  Hospital, Sacramento, Calif.
B. W. BLACK, M.D., Superintendent, Highland Hospital, Oakland, Calif.
G.    W.' ■' CURTIS)   | Superintendent,    Santa   Barbara    Cottage    Hospital,
Santa*.Barbara, California.
CAROLYN  E.   DAVIS,   R.N.,  Superintendent,   Good   Samaritan   Hospital,
Portland, Oregon.
SISTER JOHN GABRIEL, Seattle, Washington.
A. M. GREEN, D.D., Superintendent, Emanuel Hospital, Portland, Oregon.
GEORGE   HADDON,   Business   Executive,   Vancouver    General    Hospital,
Vancouver, British Columbia.
A. C. JENSON, Superintendent, Fairmont Hospital, San Leando, Calif.
R. W. NELSON) Superintendent, Portland Sanitarium, Portland, Oregon.
EMILY PINE, R.N., Superintendent, St. Luke's Hospital, Boise, Idaho.
W. W. RAWSON, Superintendent, Thos. Dee Memorial Hospital Ogden,
Utah.
J. O. SEXSON, Superintendent, Good Samaritan Hospital, Phoenix, Ariz.
PRESTON T. SLAYBACK, Business Executive, Orthopedic Hospital School,
Los Angeles, California.
ROBERT WARNER, M.D., Superintendent, Deaconess Hospital, Spokane,
Wash.
BUSINESS SESSION
BRITISH COLUMBIA HOSPITALS' ASSOCIATION
PRESIDING: Mr. J. H. McVety.
The meeting then resolved itself into a business session of
the British Columbia Hospitals' Association.
CHAIRMAN: The Financial Report, prepared by the Treasurer, Miss G. M. Currie, R.N., is as follows:
178 CASH STATEMENT
August 81, 1929, to August 14, 1930
RECEIPTS
Balance in Bank and in hand August 31st, 1929 $ 772.39
Pooling    175.04
Membership Fees—Hospital  740.00
Membership Fees—W. A  100.00
Advertising—1929 Report  _...„ Wk  260.00
Government of British Columbia—Grant for Convention 500.00
$2,547.43
DISBURSEMENTS
Pooling    $ 174.96
Bank Charges  6.20
Convention Expenses   113.05
Printing Annual Report :_..  265.20
Secretary's Salary—Sept. 1—11, 1929  9.17
Secretary's Expenses   85.96
Treasurer's Expenses  7.75
Remington Typewriters Ltd  65.00
Filing Cabinet   37.50
Brown Bros  17.50
Delegates' Expenses—Portland Convention  97.38
Delegates' Expenses—Executive Meetings  61.05
Delegates' Expenses—to Victoria  15.00
Clarke & Stuart j 35.55
C N. Telegraphs  9.68
$1,000.95
Balance in Bank $1,536.91
Cash in Hand         9.57
  1,546.48
$2,547.43
SAVINGS ACCOUNT
August 31st, 1929    Balance in Bank $965.55
October 31st, 1929    Interest added     14.45
April 30th, 1930       Interest added      14.70
August 14th, 1930    Balance in Bank I $994.70
Moved by MR. HADDON, seconded by MR. COADY, "THAT
the Treasurer's report be adopted, and that the Treasurer be
thanked for the very favorable balance."
(Motion Carried)
179 The following officers were elected, by acclamation, for the
ensuing year:
Honorary President:   HON. S. L. HOWE, Provincial Secretary, Victoria,
B. C.
Honorary Life Members:  DR.  M.  T.  MacEACHERN,  M.D.,  CM.,  D.Sc,
Associate  Director,   American   College   of   Surgeons   and   Director   of
Hospital Activities, 40 East  Street, Chicago.
MR. J. J. BANFIELD, 327 Seymour Street, Vancouver, B. C
President:  MR. J.  H.  McVETY, 411 Dunsmuir  Street,  Vancouver, B.  C.
First Vice-President: MR. J. M. COADY, 553 Granville Street, Vancouver,
B. C.
Second   Vice-President:   DR.   E.   M.   PEARSE,   Provincial   Royal   Jubilee
Hospital, Victoria, B. C
Treasurer: MISS G. M. CURRIE, North Vancouver Hospital, North Vancouver, B.  C.
Secretary:  MISS M. F. GRAY, Dept.  of Nursing and Health, University
of British  Columbia, Vancouver, B. C
REGIONAL REPRESENTATIVES
Vancouver Island: MR. A. P. GLEN, Ladysmith General Hospital, Ladysmith,  V.  I.
Vancouver: MR. GEORGE HADDON, Business Executive, Vancouver General Hospital, Vancouver.
Coast Mainland:  MR. G. W. MARSHALL, North Vancouver.
Fraser Valley: MR. R. C. McCULLOCH, Abbotsford.
Yale^Cariboo:   MR. M. L.  GRIMMETT, Merritt.
Okanagan: MR. W. B. HUGHES-GAMES, Kelowna General Hospital,
Kelowna,
Kootenay West:  MB. COZIER, Kamloops.
Kootenay East: SISTER MARY CLARISSA, Superintendent, St. Eugene
Hospital, Cranbrook.
Grand Trunk: MISS J. A. HARRISON, Prince Rupert Hospital, Prince
Rupert, B. C
CONVENERS  OF STANDING  COMMITTEES
Medical Affairs: DR. R. A. SEYMOUR, Vancouver General Hospital,
Vancouver, B. C
Business Affairs: MR. GEO. McGREGOR, 612 Humboldt Street, Victoria.
B. C
Nursing Affairs: MISS BESSIE CLARK, Royal Columbia Hospital, New
Westminster, B. C.
Constitution and By-laws: MR. E. S. WITHERS, Royal Columbian Hospital, New Westminster, B.  C
Women's Auxiliaries: MRS. A. C WILKES, St. Paul's Hospital, Van^
couver, B. C
It was decided that the meeting place of the next Convention should be left to the Executive Committee.
Moved and seconded, "THAT the Executive Committee be
asked to take up with Counsel and also with Mr. J. M. Coady,
180 the First Vice-President of this Association, the matter of an
amendment to the Workmen's Compensation Act whereby it will
not be possible for their medical referee to deduct a certain mum
ber of days from the hospital's bill, after the patient has been
discharged by his own physician."
(Motion Carried)
Moved by MR. McCULLOCH, "THAT the thanks of the B. C
Hospitals' Association be extended to Mr. J. H. McVety for his
able services throughout the Convention, and also for the service
rendered to this Association in getting a reduction in the price
of alcohol. ALSO to extend our thanks to Mr. G. W. Olson for
his great help in behalf of this Convention."
(Motion Carried)
Upon motion, the meeting adjourned.   12 Noon.
From 2 to 6 p.m. the visiting delegates were the guests of
the British Columbia Hospitals' Association on a steamer cruise
to Howe Sound. Afternoon tea was served and a large number
of the delegates availed themselves of this opportunity to see
the beautiful scenery surrounding Vancouver, and also to greet
the "Empress of Japan" on her maiden voyage.
SATURDAY, August 23rd, 1930
The delegates were invited to visit the Essondale Provincial
Mental Hospital, also the Vancouver, North Vancouver and New
Westminster Hospitals.
181 CONSTITUTION AND BY-LAWS
BRITISH COLUMBIA HOSPITALS' ASSOCIATION
: The British Columbia
Article 1—Name
The name of this Association shall be
Hospitals' Association.''
Article 2—Purpose
(a) To serve as a means of intercommunication and cooperation for the hospitals of this Province.
(b) To increase the efficiency of all hospitals in the Province by establishing and maintaining the best possible
standards of hospital service.
(c) To stimulate and to guide intensive and extensive hospital development.
(d) To develop on the part of hospitals a sense of responsibility to the community with respect to education in
health matters with special emphasis on the training
of nurses.
(e) To keep the people of this province informed concerning hospital problems and to serve as a means of communication between hospitals and those in authority
in provincial and municipal affairs.
(f) To frame from time to time suggestions for additions
to, or changes in legislation affecting hospitals.
Article 3—Membership
Members shall be all persons connected directly or indirectly
with hospitals paying the membership fees hereinafter mentioned,
and such members shall be classified as follows:
(a) Honorary
(b) Individual
(c) Institutional
(d) Auxiliary
Honorary members shall be those persons who are held by
the Association to have rendered conspicuous service in the hospital field.
Individual membership shall be all persons connected directly or indirectly with hospital work who are not members of
Trustee Boards or Boards of Directors, or who do not hold executive positions in hospitals.
Institutional membership may be held, by any hospital, public
or private, carrying on work within the Province.   Institutional
182 membership shall include all members of Trustee Boards or
Boards of Directors and all persons holding executive positions
in hospitals having membership in the Association.;
Auxiliary Membership—The senior Auxiliary or Women's
Organization duly recognized as such by the Board of Directors
of the institution it serves may be admitted as such to corporate
membership, provided the hospital with which it- is associated is
a member of the B. C Hospitals' Association.
Article 4—Officers
The officiers of the Association shall be:
Honorary President
President ..." ,,.'
First Vice-President ;«' ...•.,....
Second Vice-President ....
Secretary
Treasurer
The Executive Committee shall be composed of twenty members, as follows:
(a) The Officers of the Association l^.j
(b) The representatives of the Districts hereinafter mentioned
(c) The Conveners of the Standing Committees
The following districts must be represented on the Executive
Committee, viz., Vancouver Island, Vancouver, Coast. Mainland,
Fraser Valley, Yale-Cariboo, Okanagan, Kootenay East, Kootenay West, Grand Trunk Pacific.
Article 5—Fees ■ •'. .
Membership fees shall be due and payable on the first day
of July in each year, as follows:
Honorary Members (no fee).
Institutional Membership shall be payable according to the
following scale:
(a) Hospitals of ten beds or under, per annum .' $ 5.00
(b) Hospitals of eleven to twenty beds, per annum  10.00
(c) Hospitals of twenty-one to fifty beds, per annum.. 15.00
(d) Hospitals of fifty-one to one hundred beds,
per annum v -  20.00
(e) Hospitals of one hundred and one beds and over,
per annum _ -  25.00
Individual members shall pay a fee of five dollars per annum.
Auxiliary membership fees shall be one-half of that paid by
the Institution with which it is associated.
183 Article 6—Election of Officers
Election of Officers shall take place at the Annual Meeting
each year, and shall be by ballot. All officers shall be elected
for a term of one year. Institutional members only shall be eligible for office. Nominations shall be made only from the floor
at the Annual Meeting.
Article 7—Committees, Executive and Standing
(a) The Executive Committee shall transact the business
of the Association during the year and shall report to the Association at the Annual Meeting, or to Special Meetings when
necessary. It shall act in the capacity of a Membership Committee and shall pass upon all applications for membership in the
Association. The Executive Committee shall also act as a Legislative Committee for the purpose of considering legislation affecting hospitals.
(b) Medical Affairs. The Standing Committee of Medical
Affairs shall consist of five members, the Convener of which
shall be elected by the Association at its Annual Meeting. Its
duties shall be to investigate and report upon all matters relating
to medical service in hospitals.
(c) Nursing Affairs. The Standing Committee on Nursing
Affairs shall consist of five members, the Convener of which
shall be elected by the Association at its Annual Meeting. Its
duties shall be to investigate and report upon all matters relating
to nursing in hospitals.
(d) Business Affairs and Accounting. The Standing Committee on Business Affairs and Accounting shall consist of five
members, the Convener of which shall be elected by the Association at its Annual Aeeting. Its duties shall be to investigate and
report upon all matters relating to business administration and
accounting in hospitals.
(e) Constitution and By-Laws. The Standing Committee on
Constitution and By-laws shall consist of five members, the Convener of which shall be elected by the Association at its annual
meeting. Its duties .shall be to receive, consider and report upon
all proposed amendments of, additions to, and deletions from the
Constitution and By-laws of the Association.
(f) Auxiliary Affairs. A Standing Committee on Auxiliary
Affairs shall consist of five members, the Convener of which shall
be elected by the Association at its Annual Meeting. Its duties
shall be to receive, consider and report upon all matters affecting or relating to any Senior Auxiliary or Women's Organization
holding an Auxiliary membership in the Association.
184 (g) The remaining members of the Standing Committees
shall be appointed by the Executive Committee at the meeting
immediately following the Annual Meeting.
Article 8—Meetings:  Time and Place
The time and place at which the Annual Meeting and Convention shall be held may be decided at the regular meeting of
the year preceding or may be left in the hands of the Executive
Committee with full power to act. Special Meetings may be
called from time to time by resolution of the Executive Committee. Fourteen days' notice in advance of the holding of said
meetings shall be sent to each member of the Association.
The Executive Committee shall meet at least once a year. It
shall meet when called upon to do so by the President of the
Association or at the request of any five members of the Association.
Article 9—Quorum
Ten per cent, of the institutional membership shall constitute
a quorum of the Association at its Annual Meeting or at a special
meeting.   Five members shall constitute a quorum of the Executive Committee.
Article 10—Amendments to Constitution and By-Laws
The Constitution and By-Laws may be amended at any regular meeting of the Association by a two-thirds vote of members
present, providing that notice of motion has been given prior
to the meeting of the Committee on Constitution and By-Laws.
Article 11—Resolutions
No resolution affecting the general policy of hospitals holding membership in this Association shall be presented at any
regular or special meeting of this Association unless the same
shall have first been presented to the Executive Committee in
writing. No action affecting the general policy of said hospitals
shall be taken until the question has been referred to all institutional members, unless the question at issue shall have been unanimously agreed upon by the delegates present at said meeting.
Article 12—Voting
In any matter of business or policy requiring action by vote
of the Association, voting of institutional members shall be in
proportion of one vote for each five dollars ($5.00) of membership fee; thus an institution paying five dollars in membership
fee shall be entitled to one vote, and so forth. One delegate shall
be entitled to record the entire vote of the hospital represented
by such delegate.
185 The combined delegation of any institution or auxiliary body
shall agree among themselves as to how that institution or
auxiliary body shall vote. No institutional or auxiliary vote
shall be divided on any question. If time for deliberation is required by a delegation of an institution or an auxiliary body
before casting a vote, the chair shall postpone the taking of a
vote for a reasonable time. After postponement for such a purpose there shall be no further discussion of the question before
taking a vote upon it.
Honorary members are not entitled to vote.
Individual members shall not be entitled ' to vote at the
Annual Meeting or at any subsequent meeting of the Association
unless the membership fee shall have been paid at least thirty
(30) days prior to the holding of the Annual Meeting.
Auxiliary bodies are entitled to half the number of votes
cast by the institution with which they are associated.
Votes by proxy will not be allowed.
Article 13—Pooling of Delegates' Expenses
In the interpretation of this article, the words "travelling
expenses" are defined as being moneys actually and necessarily
expended in purchasing transportation, sleepers and berths from
the place of residence of a delegate to the Convention and return,
but shall not include moneys disbursed for meals, tips, or other
incidentals.
The travelling expenses of one delegate to the Annual Convention from each hospital holding an institutional membership
in the Association shall be pooled in the following manner,
namely:
(a) All delegates shall register with the Secretary of the
Association before the opening of each Annual Convention, and one delegate from each hospital shall at
the time of registration file with the Treasurer a statement of his or her travelling expenses (if any) certified
as correct by such delegate.
(b) On or before the closing of the Convention the Treasurer shall ascertain the average cost of the travelling
expenses of all pooling delegates, and shall pay to each
said delegate the amount that his or her said travelling
expenses exceed the said average cost, and the pooling
delegates whose travelling expenses are less than the
said avrage cost shall pay to the Treasurer the amount
of such deficiency.
(c) The Executive Committee shall have power to add to,
subtract from or otherwise amend any statement filed
under Sub-article (a) hereof.
186 BRITISH COLUMBIA HOSPITALS' ASSOCIATION
Annual Meetings Since Organization in 1918
Year
Place
President
Secretary
1918 Vancouver.... Chairmen—Dr. C H.
Gatewood, Mayor Gale,
Messrs. Grimmett, Day,
Graham and Banfield Miss J. F. McKenzie
1919 Victoria Dr. M. T. MacEachern Mrs. M. E. Johnson
(deceased)
1920 Vancouver....Dr. M. T. MacEachern Mrs. M. E. Johnson
(deceased)
1921 Kamloops JJr. H. C. Wrinch Dr. M. T. MacEachern
1922 New West'r..Dr. H. C. Wrinch Miss E. Johns
1923 Penticton Chas. Graham..... Miss E. Johns
1924 Victoria Chas. Graham Miss E. Johns
1925 Nanaimo Dr. G. B. BrOwn ,.E. S. Withers
1926 Vancouver....Geo. Haddon E. S. Withers
1927 Victoria Geo. Haddon E. S. Withers
1928 Vancouver....Geo. Haddon E. S. Withers
1929 Nanaimo J. H. McVety E. S. Withers and
Miss M. F. Gray
1930 Vancouver....J. H. McVety Miss M. F. Gray
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193 REGISTRATION
LIST OF DELEGATES, MEMBERS AND   VISITORS   WHO
REGISTERED, AUGUST 19-22, 1930
Abrams, Mrs. S. H., Vancouver, B. C.
Agnew,   Harvey,   M.D.,  Department   Hospital  Service,   Canadian   Medical
Association, Toronto, Ont.
Alexander, E. J., M.D., Supt., Salt Lake General Hospital, Salt Lake City-
Anderson, Harley C.   E.,  North  Vancouver   Hospital  Board,  North  Vancouver, B. C.
Ariss, E. Augusta, Supt., Deaeoness Hospital, Great Falls, Mont.
Armstrong, Lolo M., Western Hospital Beview, Los Angeles, Calif.
Armstrong, S. Hiles, "Western Hospital Keview, Los Angeles, Calif.
Armstrong, Mary, Vancouver General Hospital, Vancouver, B. C.
Barrett, James,  M.D.,  Melbourne, Australia.
Beard, Harry B., Director of Besearch, New England Fish Co., Vancouver.
Bethune, E. A., Vancouver, B. C.
Bingham, W. J., Chief of Police, Vancouver, B. C.
Boggs, A. Laura, Supt., Nanaimo Hospital, Nanaimo, B. C.
Black, May, Lecturer, Vancouver General Hospital Laboratories, Vancouver, B. C.
Breeze, Elizabeth G., Vancouver School Board, Vancouver, B. C.
Bronson, Adolph, M.D., Supt., Eenton Hospital, Kenton, Wash.
Broom, Mrs. G. E., Women's Auxiliary Infants' Hospital, Vancouver, B. C.
Brown, Mrs. J. A., President, Ladies Auxiliary, Princeton, B. C.
Bruee, J. Cromar, West Vancouver Hospital, West Vancouver, B. C.
Bruce, Mary D., Director of Nurses, Children's Hospital, Los Angeles,- Calif.
Buck, J. V., Supt., St. Luke's Hospital, Spokane, Wash.
Buekhalter, Edith, Mt. View Sanatorium, Taeoma, Wash.
Bulyea,  Jean, Vancouver  General  Hospital,  Vancouver, B.   C.
Burnett, W. B., M.D., Gynaecologist, Vancouver General Hospital Vancouver, B. C. ,: '■>, i
Byrne, IT. B., M.D., Provincial Mental Hospital, Essondale, B. C..
Cameron, A. V., Govt. Clinic, Vancouver General Hospital, Vancouver, B. C.
Campbell, M. E., School Nurse, Vancouver School Board, Vancouver, B. C.
Campbell, E. H., M.D., Vader Wash.
Carder, E. D., M.D., City Health Department, Vancouver, B. C.
Carson, J. H., M.D., Marpole Home for Incurables, Vancouver, B. C.
Choate, Alice, Mt. View Sanatorium, Taeoma, Wash.
Clark, Elizabeth, Lady Supt., Eoyal Columbian Hospital, New Westminster.
Clements, M. A., Provincial Mental Hospital, Essondale, B. C.
Cliffe, Mrs. S. Hughes, St. Joseph's Auxiliary, Comox, B. C.
Clute, Mrs. M. L. E., Eoyal Columbian Hospital, D.I.E., New Westminster.
194 REGISTRATION—Continued
Coady, J. M., St. Paul's Hospital Board, Vancouver, B. C.
Coburn, Eose Bell, Vancouver General Hospital, Vancouver, B. C.
Cook, E. M., Chemainus General Hospital, Chemainus, B. C.
Cornish, E. G. E., Albatross Steel Furniture Company, Los Angeles, Calif.
Corson, W. H., Supt., King County Hospital, Seattle, Wash.
Cosier, S. M., Secretary, Eoyal Inland Hospital, Kamloops, B. C.
Courser, Amy, Best Haven Hospital & Sanatorium, Sidney, B. C.
Cowan, J. G., Quesnel General Hospital, Quesnel, B. C.
Craig, Neil E., M.D., King's Daughters Hospital, Duncan, B. C.
Cunliffe, B., Vancouver General Hospital, Vancouver, B. C.
Currie, G. M., Supt., North Vancouver Hospital, North Vancouver, B. C.
Darling, George, Tranquille Sanatorium Laboratory, Tranquille, B. C.
Davis, Carolyn E., Supt., Everett General Hospital, Everett, Wash.
Dickman, Miss Anna Fong, King's Daughters Hospital, Duncan, B. C.
Duffield, Margaret, Supt. Victorian 'Order of Nurses, Vancouver, B. C.
Dutton, M. L., St. Paul's Hospital, Vancouver, B. C.
Duskin, Edna, Taeoma General Hospital, Taeoma, Wash.
Eakin, Priscilla, Emanuel Hospital, Portland, Ore.
Eaton, Esther M., Assistant Supt., Good Samaritan Hospital, Portland, Ore.
Edson, Emily H., Dietitian, Bellingham, Wash.
Ewart, M., School Nurse, Vancouver Sehool Board, Vancouver, B. C.
Fairley, Grace M., Vancouver General Hospital, Vancouver, B. C.
Fernie, Mrs. T. J., Vancouver, B. C.
Fish, F. J., Vancouver General Hospital, Vancouver, B. C.
Foley, Matthew O., "Hospital Management," Chieago, 111.
Foley, Mrs. M. O., Chicago, 111.
Forward, E., Ladysmith Geenral Hospital, Ladysmith, B. C.
Getty, Sally E., Dietitian, Provincial Jubilee Hospital, Victoria, B. C.
Gibbons, C. H., Secretary, State Health Commission, Victoria, B. C.
Gillespie, J., M.D., Vancouver, B. C.
Glen, A., Ladysmith General Hospital, Ladysmith, B. C.
Goodrich, Dorothy, Children's Orthopedic Hospital, Seattle, Wash.
Gosse, Mrs. Bichard, Infant's Hospital Auxiliary, Vanvouver, B. C.
Grant, Jessie, Technician, Vancouver General Hospital Laboratories, Vancouver, B. C
Gray, Edward J., M.D., St. Paul's Hospital, Vancouver, B. C.
Gray, Mabel F., Assistant Professor of Nursing, U. B. C, Vancouver, B. C.
Green, Axel, M., Supt., Emanuel Hospital, Portland, Ore.
Grossman, Miss E., Chilliwack Hospital Auxiliary, Chilliwack, B. C.
Grossman, Mrs. J. E., Chilliwack Hospital Board, Chilliwack, B. C.
Guymon, Mary M., Supt., F. G. Hospital, Portland, Ore.
Guernsey, Elizabeth, Vancouver General Hospital Laboratories, Vancouver.
195 REGISTRATION—Continued
Haddon, Geo., Business Manager, Vancouver General Hospital, Vancouver.
Hall, M. J., Vancouver General Hospital, Vancouver, B. C.
Hardy, C. F. M., Kootenay Lake General Hospital Board, Nelson, B. C.
Harris, Euby V.,  Technician,  Vancouver  General  Hospital Laboratories,
Vancouver, B. C.
Harrison, Jean A., Supt. General Hospital, Prince Eupert, B. C.
Harvey, Isobel, Social Service Department, Vancouver  General Hospital,
Vancouver, B. C.
Hawk, J. O., Supt., Central Washington Deaconness Hospital, Wenatchee,
Wash.
Hawkes, C. E., Vancouver General Hospital, Vancouver, B. C.
Hayhurst, E. A., Supt., Armstrong Hospital, Armstrong, B. C.
Heffter, Mrs. 0. H., Great Falls, Mont.
Henninger, Alice, Supt., Pasadena Hospital, Pasadena, Calif.
Hill, H. W., M.D., Vancouver General Hospital Laboratories, Vancouver.
Hodgkins, L., Matron, Chilliwack Hospital, Chilliwack, B. C
Horrocks, Mrs., Saskatoon, Sask.
Hull, Gordon, West Coast Hospital, Portland, Ore.
Hughes-Games, W. B., Kelowna General Hospital, Kelowna, B. C.
Jackson, Clara E., Supt., King's Daughters Hospital, Duncan, B. C.
Jefferies, H, Business Manager, Tranquille Sanitarium, Tranquille, B. C.
Jervis, J. G., B.VJSc, Lecturer Vet. Science, U. B. C, Milner, B. C.
Johnson, Howard H., M.D,, St. Luke's Hospital, San Francisco, Calif.
Johnson, Inga, Winnipeg, Man.
Jones, Emily L., Pt. Angeles Hospital, Port Angeles, Wash.
Kerr, G.,  Supt. City Hospital, Prince George, B. C
Kerr, Margaret E., Instructor, Public Health, IT. B. C, Vancouver, B. C.
King, Ernest Harold, M.D., Los Angeles, Calif.
King, Mrs. Marie, Los Angeles, Calif.
Kinney, Esther, Supt., School Lunch Booms, Vancouver, B. C.
Knox, Adda, Supt., St. Luke's Hospital, Bellingham, Wash.
Koehne, Martha, University of Michigan, Ann Harbor, Mich.
Lamb, A. S., Inspector of Hospitals, Vancouver, B. C.
Lane, C. E., North Vancouver Hospital, North Vancouver, B. C.
Lawson, Betty, Vancouver General Hospital, Vancouver, B. C.
Lee, Phyllis J., Vancouver General Hospital, Vancouver, B. C.
Leeson, Lavell H., M.D., Vancouver General Hospital, Vancouver, B. 0.
LeMarquand, J. M. A., Manager, Best Haven Hospital and Sanitarium,
Sidney, B. C.
Lenoir, Mildred, Pierce County Hospital, Taeoma, Wash.
Lewis, Bita, Vancouver General Hospital, Vancouver, B. C.
Lucas, C. F., IT. B. C. Student, Vancouver, B. C.
Lucas, Mrs. C. A., U. B. 0. Health Service, Vancouver, B. C.
196 REGISTRATION—Continued
MacArthur, M. J., Supt. of Nurses, St. Luke's Hospital, Spokane, Wash.
MacEachern, M. T., Director, American College of Surgeons, Chicago, HI.
MacDonald, M., Supt., Lanoil Beach Sanatorium, Seattle, Wash.
MacKenzie, Maizie, West Coast Hospital, Port Alberni, B. C.
MacLane, M. E., Social Service, Shaughnessy Hospital, Vancouver, B. C.
MacMaster, Annie, Wallow Tea Boom, Vancouver, B. C.
McCulloch, E. L., M. S. A. Hospital, Abbotsford, B. C.
McDonald, Eev. J. B., Vancouver, B. C.
McDonnell, C, North Vancouver Hospital, North Vancouver, B.  C.
McGregor, Geo., President Jubilee Hospital, Victoria, B. C.
McGregor, M., Vancouver, B. C.
Mcintosh, J. W., M.D., Medfieal Health Officer, Burnaby, B. C.
MeKinley, Elizabeth, H. S. Naval Hospital, Bremerton, Wash.
McLennan, M. E., Vancouver General Hospital, Vancouver, B.  C.
McPhail, Boss E., M.D., Mt. View Sanatorium, Taeoma, Wash.
McTavish, F. C, M.D., Crippled Children's Hospital, Vancouver, B.  C.
MeVety, Jas. H., Vancouver General Hospital Board, Vancouver, B. C.
Marsden,  B.,  Infants'   Department,   Vancouver   General   Hospital,   Vann,
couver, B. C.
Marshall, G. W., North Vancouver Hospital Board, North Vancouver, B. C.
Martin, M. Arkley, Supt., Home Economics, City Schools, Vancouver, B. C.
Matheson, Mrs. Wm., Vancouver, B. C.
Mayhew, Emily, St. Paul's Hospital, Vancouver, B. C.
Meitzler, Kathryn K., Cedars of Lebanon Hospital, Los Angeles, Calif.
Michie, Mrs. J. G., President, Mission Hospital Auxiliary, Mission, B. C.
Millan, J. B., Mission Memorial Hospital, Mission, B. C.
Mitchell, L., Supt. of Nurses, Provincial Eoyal Jubilee Hospital, Victoria.
Mitten, Paul L., Supt., Longview Memorial Hospital, Longview, Wash.
Moscovieh, J., M.D., Vancouver General Hospital, Vancouver, B. C.
Moots, Charles W., M.D.,   Hosp.   Eep.,   American   College   of   Surgeons,
Mentone, Calif.
Morkin, Mrs. James, St. Paul'® Hospital Auxiliary, Vancouver, B. C.
Muir, D. D., Secretary, Eoyal Jubilee Hospital, Victoria, B. C.
Munslow, H., Vancouver General Hospital, Vancouver, B. C.
Nicholls, J. O., Nanaimo Hospital Board, Nanaimo, B. C.
Nieholls, Mrs. J. O., Nanaimo Hospital Auxiliary, Nanaimo, B. C.
Noonan, Catherine, Dietitian, St. Joseph's Hospital, Taeoma, Wash.
Olson, G. W., Supt. California Hospital, Los Angeles, Calif.
Olson, Miss Etta, California Hospital, Los Angeles, Oalif.
Olson, Miss Vendla, California Hospital, Los Angeles, Calif.
Ootmar,   G.   M.,    M.D.,    Kelowna    Health    Centre    and    Laboratories,
Kelowna, B. C.
Osborne, Mrs., Vancouver, B. C.
197 REGISTRATION—Continued
Patterson, Adah H., Children's Orthopedic Hospital, Seattle, Wash.
Paris, Mrs. P., St. Paul's Hospital, Vancouver, B. C.
Pearse, G. S., Hon. Secy. West Coast General Hospital, Port Alberni, B. C.
Peele, Mrs. K. N., Boyal Columbian Hospital, D.I.E., New Westminster, B. C.
Phelps, Grace, Supt. Doernbecher Hospital, Portland, Ore.
Piket, Mrs. Len D., Pres. St. Joseph's Hospital, Comox, B. C.
Pipes, Ethel C, Dietitian, Vancouver General Hospital, Vancouver, B. C.
Quinn, Mrs., St. Paul's Hospital Auxiliary, Vancouver, B. C.
Eandal, Helen, Insp. Training Schools of B. C, Vancouver, B. C.
Eay, Mrs. A., Victoria, B. C.
Eeinemann, M., M.D., Bellingham, Wash.
Eeinhorn, C. G., M.D., Bellevue, Alta.
Eiggs, H. W., M.D., Vancouver General Hospital Board, Vancouver, B. C.
Eiley, L. A., M.D., Oklahoma City.
Eobertson, Capt., Pres. Hospital Board, Penticton, B. C.
Boss, Margaret S., Provincial Pres. King's Daughters, Vancouver, B. C.
Eowley, Ivy, M. S. A. Hospital, Abbotsford.
Eussell, Mary W., Florence, Italy.
Eyan, Katherine M., Stewart Hospital, Stewart, B. C.
Sister Aehillie, St. Paul's Hospital, Vancouver, B. C.
Sister Alype, St. Mary's Hospital, New Westminster, B. C.
Sister Clare, St. Paul's Hospital, Vancouver, B. C.
SisterFausta, St. Vincent's Hospital, Portland, Ore.
Sister Gertrude, St. Paul's Hospital, Vancouver, B. C.
•Sister Ignatius, St. Paul's Hospital, Vancouver, B. C.
Sister John Gabriel,  Educational  Director,  Sister of   Charity   Hospitals,
Mt. St. Vincent, Seattle, Wash.
Sister Joseph Auseline, Mt. St. Vincent, Seattle, Wash.
Sister Julie, St. Paul's Hospital, Vancouver, B. C.
Sister Julienne die Falconieri, St. Mary's Hospital, New Westminster, B. C.
Sister Louis, St. Paul's Hospital, Vancouver, B. C
Sister M. Flavia, St. Joseph's Hospital, Bellingham, Wash.
Sister M. Vianney, St. Paul's Hospital, Vancouver, B. C.
Sister Mary Alice, Supt. Sacred Heart Hospital, Spokane, Wash.
Sister Mary Claire, St. Joseph's Hospital, Victoria, B. C.
Sister Mary Fontan, St. Joseph's Hospital, Victoria, B. C.
Sister Mary Mildred, Supt. St. Joseph's Hospital, Victoria, B. C.
Sister Mary Patrick, Supt. of Nurses, St. Joseph's Hospital, Taeoma, Wash.
Sister Mary Vincent, St. Vincent's Hospital, Portland, Ore.
Sister Paul Ignaee, St. Paul's Hospital, Vancouver, B. C.
Sister Philip Eugene, St. Paul's Hospital, Vancouver, B. C.
SisterEaphailde, St. Mary's Hospital, New Westminster, B. C.
Sister Eosula, Sacred Heart Hospital, Spokane, Wash.
198 REGISTRATION—Continued
Sister Sophonia, St. Paul's Hospital, Vancouver, B. C.
Sister Therese Amable, Dir. of Nurses, St. Paul's Hospital, Vancouver, B. C.
Sister Theresia, St. Mary's Hospital, New Westminster, B. C.
Sister Theodore Marie, St. Joseph's Hospital, Bellingham, Wash.
Sambel, M. E., St. Paul's Hospital, Vancouver, B. C.
Sanders, Lucy C, St. Luke's Hospital, Powell Eiver, B. C.
Sehl, Florence, Matron Cumberland General Hospital, Cumberland, B.  C.
Sehl, Mrs. F. J., St. Joseph's Auxiliary, Victoria, B. C.
Seymour, E. A., M.D., Vancouver General Hospital, Vancouver, B. C.
Sheridan, Lillian M., St. Mary's Hospital, New Westminster, B. C.
Short, Doris, Vancouver General Hospital, Vancouver, B. C.
Slaybaek, P.  T., Business Executive,  Orthopedie Hospital,  Los  Angeles.
Slaybaek, Mrs. Preston, Los Angeles, Calif.
Smith, Miss E. Blanche, Supt. Anaeortes Hospital, Anaeortes, Wash.
Smith, Euth, Supt. Mt. View Sanatorium, Taeoma, Wash.
Spackman, C. E., Vancouver General Hospital, Vancouver, B. C.
Stacey, T. J., Vancouver, B. C.
Stalker, H. F., M.D., Vancouver General Hospital, Vancouver, B. C.
Staple, Lillian M., Ladner, B. C.
Stevenson, M. C, Vancouver General Hospital, Vancouver, B. C.
Stewart, Helen A., Public Library Assn., New Westminster, B. C.
Struthers, Florence B., Asst. Supt. Oakhurst Sanatorium, Elma, Wash.
Swope, Ethel, Ex-Sec'y Dist. 5, State Nurses' Assn., Loa Angeles, Calif.
Swope, Eebecea L., Social Service Worker, Los Angeles, Calif.
Taylor, Edythe A., Eoyal Victoria Hospital, Montreal, Que.
Tedlock, Mrs. N. W., St. Paul's Hospital Auxiliary, Vancouver, B. C.
Thomas, J. J., North Vancouver Hospital Board, North Vancouver, B.  C.
Treffry, Carrie M., Kootenay Lake General Hospital, Nelson, B. C.
Turner, Irene M., All Nations Clinic, Los Angeles, Calif.
Thornton, E. Beaumont, Supt. Memorial Hospital, Mission, B. C.
Twornicki, Mrs. Maud! M. T. de, Vancouver, B. C.
Underhill, F. T., M.D., Medical Health Officer, Vancouver, B. C.
Wakely, Mrs. A., St. Paul's Hospital, Vancouver, B. C.
Walkem, Geo. A., M.L.A., Bepresenting Provincial Govt., Vancouver, B. C.
Walker, F. H., Vancouver General Hospital, Vancouver, B. C.
Walker, Mrs. P., Victoria, B. C.
Walmer, T., Dept. Provincial Secretary, Victoria, B. C.
Ward, Mrs. L. B., Matron, Hospital for Crippled Children, Vancouver, B. C.
Warner, Eobert, Deaconess Hospital, Spokane, Wash.
Weigle, Mrs. M., Nanaimo Hospital, Nanaimo, B. C.
Welch, Mrs. M., St. Paul's Hospital, Vancouver, B. C.
Westmoreland, J., Secy. North Vancouver Hospital, North Vancouver, B. C.
Whitehead, Ursula, Asst., Jubilee Hospital, Victoria, B. C.
199 REGISTRATION—Continued
Wilmot, Mrs. M. E., Supt. Kelowna Hospital, Kelowna, B. C.
Wilkes, Mrs. C. J., Convener Auxiliary Affairs, Vancouver, B. C.
Withers, E. S., Eoyal Columbian Hospital, New Westminster, B. C.
Wright, Dora K., Junior High School Cafeterias, Vancouver, B. C.
Wyness, Frances D., Vancouver General Hospital, Vancouver, B. C.
Young, H. E., M.D., Provincial Health Officer, Victoria, B. C.
Young, Dorothy S., Vancouver General Hospital, Vancouver, B. C.
Zinkam, N. B., Eoyal Alexandra Hospital, Edmonton, Alta.
200

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