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386 training of the individual nurse and also the ratio of nursing per- sonnel to hospital beds. A general hospital with a minimum of 50 beds may be sanctioned as an authorized school of training for nurses with permission to grant to the successful candidate a certifi- cate of proficiency. It is well known that the standard of hospital training of a nurse varies widely in different hospitals, depending very largely on the requirements of the individual matron. In some hospitals the standard required of the nurse is very high; it may be even too high, calling for the comment from competent judges that a nurse's training should be restricted to nursing matters and not trespass into the domain of the medical man ; while in other hospitals the standard of training is very much lower. Both sets of nurses " qualify " and issue from their respective training schools into the service of the public, each possessing her certificate of proficiency. The public have no means of judging as to the quality of the train- ing of the nurses they seek to employ beyond the general label that " she is a certificated nurse."

The probationer nurses receive technical lectures from the matron and her senior assistants and from members of the junior medical staff of the hospital. Unfortunately there are too many hospitals to-day where the same individuals who give the tuition constitute the examining body, whereas in the larger hospitals one or more " external " examiners are appointed to share in the examination of the candidates. It is surely obvious that in such an important profession as nursing there might have been evolved ere this some definite minimum standard of proficiency applicable to all training schools. Again, it is not suggested that hospitals be asked to conform to some rigid mould of training, but in the interest of nurses them- selves, and especially of the general public, some minimum standard should be fixed below which no hospital should fall.

A parallel illustration might be quoted in the final examination of the medical student, for it was only after the General Medical Council instituted a system of inspection of the various " final " examinations held throughout the country that something approach- ing a minimum standard of proficiency was adopted. Further, in regard to the ratio of nurses to beds, hospitals show a considerable range of difference, even after making due allowance for the variety in architectural structure of the buildings. The absence of any standard in this connexion makes it very difficult to institute a com- parison .between similar hospitals and renders of little value the figure quoted by hospitals as being the " cost per bed," for it is obvious that if one hospital employs more staff than its neighbours, the cost of provisions consumed by them but attributed to the patients will be higher, and so also with salaries and wages.

In conclusion, it may be stated that there is practically no depart- ment in a general hospital where some basis could not be arrived at for instituting standards of efficiency. Such standards would be of considerable value to the hospitals themselves and also to the general public, both in regard to economical administration and in the general service to the community; but owing to the want of knowl- edge of each other, hospitals at present lack the information that would be of so great value in the establishment of standards. This knowledge would readily be forthcoming under a system of hospital coordination, and the institution of some such system seems the most essential step towards a solution of the present-day hospital problem. (N. B.)

UNITED STATES

The hospitals of the United States in the years 1910-21 grew in number and made progress in the acquirement of national characteristics and fixed economic and social importance. In 1921 there were in the United States 7,667 hospitals maintaining 695,698 beds; in addition 24,394 beds were used for hospitai purposes in homes for aged and in similar institutions. Table I. presents an analysis of these hospitals.

TABLE I. U.S. Hospitals.

Public: supported by taxation.

Private: supported by earnings, endowments and contributions.

Federal, State, County, Municipal.

Proprietary, for profit.

Voluntary Corpora- tions not for profit.

Small hos- pitals for patients of one pro- prietor a physician or surgeon.

L a r ger i n stitu- tions for patients of a group of owners.

Church

Non-Sec- tarian. (Covering the larger endowed general hospitals, including those con- n e c t ed with uni- versities.)

Hospitals for special groups maintained by

Fraternal Large Orders. Industrial Plants.

The proprietary hospitals show a much larger proportion of the total number of hospitals than of the total number of hospital beds, as most proprietary institutions have less than thirty beds. Larger proprietary institutions are divided into two classes. Some are jointly owned by two or more physicians or surgeons who combine to gain the increased facilities and efficiency ob- tained by pooling the volume of their professional business. Others are controlled by specialists corresponding to the depart- ments of a general hospital including X-ray and all forms of laboratory work. This was a recent development and the number of such hospitals was in 1921 few, but they showed great effi- ciency. The numbers will increase and in 1921 there was evi- dence that the basic idea commonly called "group practice" was bettering the professional service in other hospitals.

The hospitals in 1921 were classified by capacity as follows:

Bed Capacity Hospitals Percentage

Under 25 3, no

25 to 49 50 to 99 100 to 199. 200 to 499. 500 to 999. i ,000 and over

i,859 1,263

781

45 116

133 7,667

40-56 24-24 16-47 10-19 5-28 1-52 1-74

In discussing the number of active hospital beds (exclusive of convalescent and allied institutions and hospitals for nervous or mental diseases) needed by a given population, the figures for

TABLE II. Hospitals and Active Hospital Beds by States, and Ratio of Beds to Population.

States

Hos- pitals

Beds

Ratio of Beds to Pop.

Alabama

84

4,214

to 557

Arkansas

58

3,147

to 556

Arizona.

66

2,285

to 146

California

409

27-384

to 125

Colorado

109

8,629

to 1 08

Connecticut

71

6,466

to 213

Delaware

16

1,005

tO 221

District of Columbia

28

5,160

to 84

Florida

61

2,436

to 397

Georgia

88

4- 26 3

to 679

Idaho

57

1,738

to 238

Illinois

304

29,215

tO 222

14.8

8,902

to ^2Q

T-^

IQt

8 T.2I

iw O*V

to 289

Kansas

122
 * yo

u .o

4-95

to 357

Kentucky

87

5,134

to 471

Louisiana

53

5,553

to 324

Maine

56

2,477

to 310

Maryland

70

9,319

to 156

Massachusetts

298

23,3H

to 165

Michigan

206

16,384

to 224

Minnesota

212

1 i ,903

to 2OO

Mississippi Missouri

50 149

2,017 12,476

to 887 to 273

Montana

99

4,238

to 129

Nebraska

IOO

4,894

to 265

Nevada

27

734

to 105

New Hampshire. .

52

1,994

tO 222

New Jersey New Mexico

127

54

12,121

3,939

to 260 to 91

New York .'....

537

66,274

to 157

North Carolina ....

112

5,641

to 453

North Dakota

67

2,476

to 261

Ohio

280

19.059

to 302

Oklahoma

99

3.292

to6i6

Oregon

98

4,127

to 190

Pennsylvania

378

38,962

to 224

Rhode Island

32

3.291

to 184

South Carolina ....

57

3,640

10463

South Dakota

70

2,892

to 220

Tennessee

86

7,452

to 314

Texas

225

12,300

to 379

Utah

46

1.965

to 229

Vermont



1,083

to 325

o * 1 06

7 SS'*

to "*o^

Washington

162

/ .000

8,384

vv ^ J *J

to 162

West Virginia

74

3,636

to 402

Wisconsin

95

11,106

to 237

Wyoming

4 2

2,520

to 77

Outlying Possessions

131

13.902

to 758