Object of Work—Districts—Hours on Duty—Number of Daily Visits—The
Nurse’s Office—Lunch and the Noon Hour—Bags—Prophylactic
Supplies—Cups, Fillers, and Napkins—Disinfectant—Waterproof
Pockets—Books of Instruction—Stocking the Bag and Distributing
Supplies—Nursing Supplies.
=Object of Work.= The object of tuberculosis nursing is the home
supervision of all persons suffering from pulmonary tuberculosis. This
supervision should include patients in all stages of the disease, and
not be limited to those who are in some particular stage, such as early,
in contradistinction to advanced, cases. No organization which expects
to do effective work should deal with one class of patients alone, since
the boundary lines between the different stages are constantly shifting;
the ambulatory case of to-day may be the bed-ridden case of to-morrow,
and _vice versa_, and any attempt to limit the nurse to one class or the
other would mean neglect of both. Unless the work is planned on such
inclusive lines, it will be necessary to place a second organization in
the field, to care for those cases which have been thrown out by the
first. Policy of this sort would mean a number of similar organizations,
duplicating and overlapping each other’s work at every turn. Thus, in
the same household, we should see the early, ambulatory patient
“advised” by the nurse of one organization, while the advanced,
bed-ridden, more infectious case is being bathed and cared for by the
nurse from another. Invidious comparisons would doubtless be made by the
family, with the decision in favour of “deeds, not words.” True, there
would be co-operation between these two societies,—which would mean, as
a rule, double work, duplication of visits, endless transferring of
cases backwards and forwards, and opening and closing of records. From
whatever point of view we consider it, this is a very poor plan of work,
and a wasteful method. The nurse should be in a position to follow the
fortunes of her patients for months and years. Any scheme which involves
transferring him to a stranger, from an old friend to a new, at the
moment when he slips from an early into a most infectious stage, is to
lose sight of him and of his family at a most critical time.
Adequate supervision means that the nurse must teach, nurse, and ferret
out patients, and her patients must include advanced, early, and
suspicious cases. The care should be of two kinds—instruction as to the
nature of tuberculosis, with general teaching along the lines of
prevention and prophylaxis; as well as actual nursing service, rendered
to advanced and bed-ridden cases. The Baltimore nurses take charge of
all tuberculous patients, in whatever stage, and we feel that this is
the most effective way to carry on the work.
=Districts.= A small town, of course, constitutes but one district in
itself. A larger town may be divided into two or three districts; a
city, into as many as may be necessary. The principles upon which the
work is conducted are the same in each case. The nurse is responsible
for every consumptive in her district, and her constant endeavour should
be to bring under supervision every case of tuberculosis that exists.
She must visit all patients referred to her—give them instruction,
prophylactic supplies, and nursing care; unearth suspicious cases and
send them to a physician for diagnosis; secure hospital or sanatorium
treatment for those who are eligible, and arrange all details connected
with their admission. To accomplish these duties, she must know the
physicians of her district, the dispensaries and institutions where she
may send her patients, the philanthropic or relief-giving agencies whose
aid is so often needed, and all social workers whose co-operation is
necessary for the furtherance of the work in hand.
=Hours on Duty.= Eight hours should constitute the working day, from
eight or nine in the morning, till four or five in the afternoon. With a
large staff, the day will probably not begin till 9 A.M., while a single
nurse, in a small community, may prefer to begin earlier and so finish
earlier, especially in summer. It is a mistake to work overtime, no
matter how interested and enthusiastic one may be. A peculiarity of
tuberculosis work is its unending character—there is always more to do
than can be crowded into the longest day, and even after working ten,
twelve, fourteen hours, one would always feel that some important thing
was being left undone. It is well to recognize this fact in the
beginning, although the temptation to make “just one more” visit is
often hard to resist. The nurse who habitually works overtime only wears
herself out the faster, and in the end her patients will suffer through
her loss of health and energy.
=Number of Daily Visits.= This is a variable factor, and depends in
great measure upon the size of the district, as well as the number of
patients it contains. The character of the service rendered also
determines the number of visits, as new patients and bed-ridden patients
always demand considerable time. If a nurse calls on ten patients in a
block, and finds none of them in, she naturally can make more visits
than when compelled to spend a long time in each house. As in everything
else, it is the quality that counts, rather than the quantity; the day
which shows few visits may have been spent more profitably than that on
which she scored a high total. There is no general rule as to a nurse’s
capacity, yet it is always well to suspect the value of a large total of
daily visits; if a nurse dashes in and out of a house, spending but a
few moments with her patients, she has probably done her work so
superficially that nothing has been accomplished.
On the other hand, some nurses pay far too few visits because they have
no head for planning their work, but linger, past all necessity, over
unimportant details. To judge if a district is being properly visited,
the superintendent should know the district, and she should also know
her nurse’s capacity. To estimate the value of the day’s work by the
number of visits alone, is like those societies who reckon their value
by the number of pieces of literature they distribute, totally
regardless as to whether any of it bears fruit.
Roughly speaking, each patient should be visited once a week; failing
this, once every ten days or two weeks. In a few exceptional instances,
this time between visits may be still further extended, but this should
happen only when the patient is doing extremely well, following all the
rules, and giving efficient and intelligent co-operation. There are not
many patients in this class—for the average, supervision to be adequate
must be frequent.
Very ill patients, however, must be seen two or three times a week—every
day would not be too often, did the work permit. Unfortunately, if the
visiting list is large, these sick patients can be visited only at the
expense of other cases better able to take care of themselves. For this
reason, the visits to ambulatory patients may become as infrequent as
once every three weeks. If the visiting list grows so large that these
infrequent visits are all that the nurse can give, then her instruction
is laid on so thin as to be nearly worthless, a condition of affairs
which calls for another nurse.
=The Nurse’s Office.= An office is a necessity for the nurse as a place
where she may keep her nursing and prophylactic supplies, and at which
she will report at certain hours of the day, say at 9 A.M., at lunch
time, and possibly again in the afternoon before going off duty. At
certain specified hours, therefore, it will be possible to reach her,
either in person or by telephone, and her office hours should be known
to doctors, social workers, patients, or to any who have need to call
upon her. In a small town or country district, there will of course be
only one office, but in a city it will be necessary to have several
branch offices, accessible to the nurses of the different districts.
These branch offices should be situated on the border lines of two or
three adjoining districts, so that one office may be used in common by
several nurses. In a city there is also the central office, from which
the superintendent directs the work, and where the staff nurses report
daily.
In Baltimore[2] these branch offices are usually in the same building
which houses a branch of the Federated Charities, the branch office of
the Visiting Nurse Association, the Infant Welfare Association, and
other similar agencies. In this way, the various social workers learn to
know each other, and to secure close co-operation and understanding. The
different agencies, however, each have their separate rooms or offices.
Footnote 2:
Baltimore is divided into sixteen nursing districts, with eight branch
offices or sub-stations, for the use of the sixteen nurses.
The nurse’s office should be simply but comfortably furnished. It is
used for several purposes—as a store room for supplies, and as a rest
room, where she takes her lunch and spends an hour off duty in the
middle of the day. The furniture should consist of a large writing
table, which may also be used for a dining table; chairs, a lounge or
couch, and a small gas stove or Bunsen burner for cooking simple meals.
If there is no available closet, there will have to be a commodious
cupboard for storing the prophylactic supplies. A large stock of these
must always be kept on hand, so that the nurse may refill her bag before
starting out again on her afternoon rounds. A telephone in the office,
or at least in the same building, is of course necessary.
=Lunch and the Noon Hour.= It is not within the province of a
superintendent to dictate to her nurses as to what they shall eat. The
association, be it private or municipal, furnishes the office and the
hour, but the nurse must provide her own lunch and select it according
to her fancy. A word, however, in regard to this lunch. It should be as
nourishing as possible, and should consist of such wholesome food as
eggs, milk, cocoa, and so forth. If a nurse substitutes a pint of milk
for a cup of tea or coffee, she is wise.
In addition to nourishing, wholesome food (in contradistinction to
unprofitable pie and buns from the neighbouring bakeshop), a short
period of relaxation on the lounge or couch is a wise way in which to
spend a portion of the noon hour. In dealing with tuberculosis, food and
rest are necessary to keep one strong and well, and no nurse can afford
to trifle with her health when engaged in this serious work. On no
account should the noon hour be cut short, no matter how little tired
she may be. Better work can be done if one is well fed and rested.
=Bags.= The association which employs the nurse should also provide her
with the bag for carrying the supplies. The kind of bag needed is a much
discussed question. It should be strong, even though this necessitates
its being heavy. There is no other way out of it—for unless the bag has
the first qualification, strength, the weight of the supplies will soon
wear it out. Very light bags are not practical.
The bags used in Baltimore are made somewhat like the ordinary Boston
bag, about fourteen inches long, and of good black leather. They weigh a
few more ounces than those used by other associations, but they last
longer. It must also be remembered that the bag used by the tuberculosis
nurse, no matter how heavy it is when she starts forth on her rounds,
grows lighter and lighter as she goes from house to house, leaving the
supplies. Thus, at the end of the day, when she is most tired, it is
practically empty.
=Prophylactic Supplies.= The prophylactic supplies used for the patients
consist of tin sputum cups, cardboard fillers, paper napkins, waterproof
pockets, disinfectant, and books of instruction. The first three are of
primary importance. The Health Department of a community usually
provides these supplies, even when the nursing work is carried on by a
private association. Thus, in Baltimore, where for six years the
tuberculosis work was done by the Visiting Nurse Association, an
arrangement was entered into between this Association and the State
Board of Health, according to which, the latter paid for and provided
the supplies which the nurses distributed. The only condition imposed
was that each case should be reported to the Health Department, and that
the Health Department should be constantly advised as to the number of
cases under supervision. If no such arrangement is possible, then the
private association supporting the nurse must be put to the additional
expense of buying the supplies.
It is impossible to make the patients themselves pay for them.
Naturally, they consider them a nuisance and a bother, and it is
difficult enough to persuade them to use them, even when given free. The
cost is not great, however.
Tin sputum cups, (in lots of 5000) 7 cents apiece.
Fillers, (in lots of 1,000,000) $3.50 per thousand.
Paper napkins, (in lots of 5,000,000) $.55 per thousand.
Disinfectant, 10 cents a bottle.
Waterproof pockets 4 cents apiece.
Books of instruction 2 or 3 cents apiece.
=Disinfectant.= The most expensive of the supplies is the disinfectant,
which is also probably the least valuable. That used in Baltimore is a
special preparation, consisting largely of creolin; it is put up in pint
bottles by one of the large wholesale drug houses. For use, it is
diluted in water, a tablespoonful to a pint, and used in wiping up
floors, furniture, and so forth. It is of necessity too dilute to have
much germicidal action, and the patients place far too much reliance
upon its odor—which, to the ignorant mind, is of prime importance.
Although we use this disinfectant, we prefer to teach our patients that
better results may be obtained by the lavish use of hot water, brown
soap, and a scrubbing brush, and that thorough cleaning of this kind is
of more value than the most malodorous drug ever dispensed. Disinfectant
to be of real use must be strong and powerful, and it is dangerous to
distribute such powerful drugs promiscuously. Several of our patients
have tried to commit suicide by drinking even the weak preparation that
we gave them. On the whole, we believe that an anti-tuberculosis society
would lose nothing by omitting disinfectant from its list of
prophylactic supplies, and better results could be obtained by
substituting a thorough grounding as to the value of soap and water.
=Waterproof Pockets.= These are little calico bags, dipped in paraffin,
or some similar preparation which makes them fairly waterproof. These
are pinned inside the coat pocket, and the patient uses them as a
receptacle for his soiled napkins, when he is out on the street, or in
other places where he cannot carry his sputum cup. The napkins are
burned upon his return.
=Books of Instruction.= These little books are more or less valuable,
but are by no means intended to take the place of the verbal instruction
which it is the nurse’s duty to give. They serve merely to refresh the
memory after she has gone. They can be procured at small cost through
the various anti-tuberculosis organizations, and most Boards of Health
print them for their own distribution. The best of them are inadequate.
=Stocking the Bag and Distributing Supplies.= When the nurse starts
forth on her morning rounds, her bag should contain enough supplies for
the patients she proposes to call on. Each should be given enough to
last until her next arrival. It is sometimes possible to direct either
the patient himself, or some member of his family, to come to the office
and get a fresh stock whenever necessary. By putting this slight
responsibility on the family, it is made to realize how necessary are
these supplies, but it should not relieve the nurse of her obligation to
visit such a household, and keep it under as close observation as any
other case. If a nurse thus trains a certain number of patients to come
themselves for the supplies, she will be able to reserve the contents of
her satchel for those patients who cannot call for them, or who are too
indifferent to do so.
Supplies should always be given out freely, and the patient should not
feel that he is put under any obligation by accepting them. They are
intended for his personal use and convenience, and he should be made to
realize this. Otherwise, some patients may hesitate to accept all that
they really need. If a patient needs four or five fillers a day, he
should unquestionably have them—otherwise he may practise small
economies which will mean unnecessary exposure for his family. On the
other hand, the nurse must see that the supplies are used for the
purpose intended—we have sometimes known handkerchiefs used as a
decoration for kitchen shelves, simply because the nurse had given away
far more than was necessary.
=Nursing Supplies.= In addition to the prophylactic supplies, the bag
also contains a number of articles used in caring for bed-ridden or very
ill cases. Naturally, these articles are not given to the patients, but
are used from case to case, as necessity arises. They include a bottle
of alcohol, boracic ointment, talcum powder, gauze, adhesive strapping,
absorbent cotton, and a thermometer. The nurse should always carry an
apron, to be worn when doing any nursing work.
The most common dressing is that of bedsores; many patients with
pleurisy have to be strapped; others have drainage tubes, which must be
taken out and cleaned. These extensive dressings are not those which the
nurse should properly be required to attend to, since a patient ill
enough to require an extensive dressing, is a patient who should be sent
to a hospital. Hospital accommodation, however, is unfortunately very
limited, and the nurse is often obliged to do these dressings while
waiting for a vacancy to occur. It is no part of the programme to keep
these advanced cases at home rather than in an institution; on the
contrary, the nurse must make every effort to get them away—but until
this can be accomplished, it is her duty to care for them at home.