The Nurse in Relation to the Institution—Reports Made to the
Institution—Procuring Patients for it—The Value of the
Sanatorium—Sanatorium Outfit—Return from the Sanatorium—Work for
the Arrested Case—Light Work—Outdoor Work.
=The Nurse in Relation to the Institution.= As the nurse is the
go-between from patient to physician, and from patient to dispensary, so
also does her service link together patient and institution. This, of
course, is only possible if she is a public health nurse—not if she is
the agent for one institution alone, or if she is employed to serve one
set of people instead of the community as a whole. Just as she should be
at the service of every physician, dispensary, and layman who chooses to
call upon her, so in like manner should she serve both hospital and
sanatorium. She will act as beater-up in the matter of sending patients
into these institutions; will arrange all details connected with their
admission, and finally, upon their discharge, will take them again under
her supervision and care. By this co-operation, the patient himself
profits, likewise the community, while the institutions are enabled to
keep in touch with their discharged cases, learn of their condition,
and, through the nurse’s reports, add to their histories and records
from time to time in a way which will greatly enhance their value.
There is complete co-operation between the various institutions of
Baltimore and the nurses of the Health Department. Of the five
institutions near the city, four admit both early and late cases, while
one is for advanced cases only. Whenever a patient is admitted to or
discharged from one of these institutions, either hospital or
sanatorium, the Health Department is at once notified of the fact.
Following admission, the nurse visits the home and arranges for the
fumigation. Two thirds of the patients admitted are already known and
under supervision, but whether known or unknown, the visit is made and
fumigation arranged for in the usual manner. In homes where the patient
is unknown, the nurse often finds suspicious cases, which she sends for
examination and diagnosis. By means of this sharp look-out the visiting
list is considerably augmented.
When the discharge of a case is reported, the patient may or may not
have been under previous supervision. If already on the visiting list,
the nurse merely resumes her visits. If not on the list, he is taken on
at once. Needless to say, the physician in charge of the institution
should prepare the way for the nurse’s coming, as should the physician
of the dispensary. If he forgets to do so, the nurse may have some
difficulty, especially with patients discharged in good condition, who
see no need for her services. When discharged in bad condition, the
reason is obvious enough, but in either case co-operation with the
institution is necessary.
=Reports Made to the Institution.= The reports made to the institution
vary in accordance with the wishes of the physician in charge. Sometimes
they are informal, made on certain specified cases; sometimes they are
extensive and deal with large numbers of individuals. The value of these
reports is indicated by the following examples: Two months ago a young
girl was admitted as a paying patient, but she is now at the end of her
resources, which consisted of a small fund subscribed through
contributions of her fellow-workers. If she is to remain longer at the
sanatorium, she must be transferred to the free list. Or we find that a
young man, admitted erroneously to the free list, is in a position to
pay; in justice to the institution and those who perforce must accept
its hospitality, this patient should be transferred to the paying side.
Or we receive a letter from the superintendent, saying that a certain
patient has failed to arrive on the day specified, and asking us to look
into the matter. Upon investigation we may find that a death in the
family, an accident, or the lack of railway fare has been the cause of
his non-arrival. Provision for him to go can then be made—his place is
not forfeited, but held for him until a more favourable time. These
personal relations between the nurse and the institution bring a great
sense of cordial understanding and mutual good-will.
The more extensive reports are managed as follows: Once a year, or
oftener if necessary, certain institutions send to the Health Department
a full list of their discharged patients, whom they wish looked up. The
names and addresses are written on separate slips of paper, which
contain a printed list of questions to be answered. These are
distributed among the nurses of the different districts, each nurse
being responsible for the patients in her own territory. Within a week
or ten days all the slips are filled in, and a full return made on all
cases submitted for investigation. This involves little extra work on
the part of the nurses, since in nearly every instance the patients are
already under supervision—and if through any oversight they are not, it
affords a means of finding them. The superintendents of the various
institutions find this a satisfactory way of keeping in touch with their
ex-patients, and we think that this work is well within the field of the
visiting nurse. Each gains by this co-operation—the Health Department,
which wishes to supervise all consumptive patients, and the institution,
which wishes accurate data for its reports. In effective social work the
keynote of success is reciprocity.
=Procuring Patients for the Institution.= In still another way does the
nurse serve the institution and that is by procuring patients for it.
Large, well organized, and well equipped institutions have little
difficulty in filling their beds, but this is often the reverse with
those less known and less attractive. It takes much persuasion to induce
a sick man to leave his home, and it often takes still more to persuade
his family to let him go. To point out the necessity for institutional
care, and induce the patient to take advantage of this, is the chief
duty of the public health nurse. Only when she does this duty thoroughly
and well does the demand for hospital beds exceed the supply. For
example: in Baltimore, before the nurses went on duty, the large
hospital for advanced cases was never more than half full. The community
was not well enough educated to take advantage of it. Since the nurses
have been on duty, however, not only has this hospital been filled to
capacity, but the capacity itself has been enlarged to nearly
double—while a long waiting list is constantly maintained. A small
sanatorium was recently opened in Maryland, with a capacity of twenty
beds; at the end of five months, it had only five patients. The nurses’
aid was solicited, and within a week it was full. This situation has
also occurred in other cities, which found themselves equipped with
excellent hospital accommodations, which the patients refused to make
use of. Co-operation between the institution and the municipal or
visiting nurses would doubtless have promptly remedied this state of
affairs. Incidentally we may observe, the better managed and more
comfortable the institution, the less difficulty there is in keeping it
full. It must offer substantial advantages over the home—attractions
which even the most ignorant and prejudiced must be trained to
appreciate.
=The Value of the Sanatorium.= The sanatorium for the treatment of
hopeful cases is by no means as valuable as was at first expected. The
cure of tuberculosis is at best very problematical, and the sanatorium
is chiefly useful to those who can control their environment upon
discharge. Unless this can be done, treatment will be of little avail,
although it will delay the inevitable end. The patient who comes from
the alley and returns to the alley is foredoomed. And as most patients
come from the alley, figuratively speaking, and are afterwards obliged
to return to it, the results obtained by these sanatoriums are by no
means commensurate with the expense involved in maintaining them.
Whatever benefit is derived from them is for the individual, rather than
for the community.
In the tuberculosis campaign, the sanatorium occupies a place of
secondary importance. We could fight quite as successfully without
it—possibly better, since the money devoted to the upkeep of these very
costly institutions could then be diverted to more radical purposes.
However, the sanatorium exists, and every patient should be given his
individual opportunity. It is usually more difficult to get a patient
into a sanatorium than into a hospital. The former is for early or
moderately advanced cases, who have a reasonable chance of improvement,
therefore it would seem a simple matter to induce them to go. Yet to
persuade a patient that he needs such treatment, especially when he
feels well and has few symptoms, is often a difficult task. The peculiar
psychology of the consumptive, his optimism and refusal to believe that
he has tuberculosis, is as well marked in the early as in the later
stages of the disease. On the other hand, the difficulty is often of an
economic nature. When the patient stops work, his income ceases, and
this often determines his refusal. This is why many patients work until
they drop in harness. Through the Charity Organization, or other similar
agencies, it is possible to solicit aid for a certain number of these
cases, and this must always be done. Such relief, however, is very
uncertain, and latent periods of considerable duration often intervene
between the time it is asked for and such time as it may be given. Even
when given, it very seldom approximates the wages that the patient
himself has been able to earn. Thus, a patient earns twenty dollars a
week; with luck, we may obtain for his family an income of eight or ten.
This is no reflection upon the Charity Organization Society, which has
probably pulled every conceivable wire in order to raise even that
amount—but it explains why the patient refuses the sanatorium and hangs
on to his job until he can work no longer.
In many cases on the other hand, there is no question of poverty to
contend with—neither the wage-earner’s reluctance to stop work, nor the
mother’s unwillingness to leave a houseful of little children. Instead,
we must contend with ignorance, prejudice, and mental inertia—a moral
alley quite as dark as that of the slum. One of the most discouraging
features of this work is having to stand by and see the patient throw
away his chances. Tuberculosis waits for no one, and it requires not
only physical, but mental and moral strength to resist it. Before we can
remake and reconstruct a supine individual, the disease wins out in the
race.
There is one consolation, however; hopeful cases are usually far less
dangerous than advanced ones. The refusal of sanatorium treatment is a
loss to the individual only. Furthermore, we have this grim solace—when
they finally consent to go, after weeks and months of delay, they do so,
too late to help themselves, it is true, but at a time when they are
most dangerous to other people.
=Sanatorium Outfit.= When a patient enters a sanatorium, the nurse must
see that he is supplied with clothing heavy and warm enough for outdoor
living. If he has money, he should be instructed what to buy. If he has
none, these things must then be procured through some charitable
association. No patient should be permitted to enter a sanatorium unless
properly equipped, and frequently his decision against going is due to
lack of such equipment.
In winter, he naturally requires much more than in summer. Roughly
speaking, his wardrobe should contain at least two changes of flannel
underclothing, a sweater, overcoat, woollen cap, woollen gloves,
overshoes, flannel night clothing, a dressing-gown, toilet articles, and
a hot-water bottle. Some institutions have a printed list of the
articles required, which is sent to the patient when his application is
accepted. A steamer rug is usually necessary, a cheap substitute for
which may be found in the large horse-blanket, sold in saddlery shops.
=Return from the Sanatorium.= When a patient returns from a sojourn in
an institution, he may or may not be better, but he has certainly
received a liberal education in what to do, and how to take care of
himself. Often, however, he is totally unable to apply this knowledge,
or to adapt his home environment to his needs. So carefully is the
institutional life planned, and so smoothly does he fit into it, that he
has no conception of the time and thought that have gone into this
planning. When he comes home, he knows theoretically what to do, but in
comparison with the institution his home surroundings seem so poor and
so inadequate, that he becomes hopelessly bewildered and confused. It is
at this point that the nurse has her great opportunity. She teaches him
to apply what he has learned, and how he may approximate sanatorium
conditions and routine. She goes to work much as she does upon her first
visit to the home, but this time she is working in a soil already
ploughed. The patient himself may be almost as helpless, but he will
follow suggestions, and co-operate with an intelligent enthusiasm gained
through his sanatorium education.
=Work for the Arrested Case.= When a patient returns from the sanatorium
able to work, the question of employment is a serious one. Our
experience has been that of Dr. Lyman:[8] as a rule, unless it is an
exceedingly injurious employment, it is better to let him return to his
former occupation than to seek a new one. He understands his old work,
and for this reason it will be easier for him than one to which he is
unaccustomed. The difficulty of finding suitable employment for arrested
cases, and the number of relapses that occur in consequence, serve once
more to emphasize the value of prevention rather than cure.
Footnote 8:
Dr. David R. Lyman, Wallingford, Connecticut.
There is one point which must always be brought out. It is not so much
what the patient does with his working hours, as what he does with his
leisure hours, which determines his ability to hold his own. An arrested
case may work eight or ten hours a day, in office, factory, or shop, and
still remain well, provided he spends the remaining hours of the
twenty-four in a proper manner. The ex-sanatorium case, rejoicing in his
apparently restored health and in his regained liberty, feels that he
can resume life on exactly the same terms as before. This he can never
do. He has tuberculosis, and he always will have tuberculosis, although
it may be latent at the moment. The fact that it is quiescent does not
mean that it will not light up again at the slightest indiscretion. He
must bear this fact constantly in mind and order his life accordingly.
If he expects to work and remain well, he cannot burn the candle at both
ends, even in the mildest manner. He must forego late hours, moving
picture shows, poolrooms, saloons, dance halls—everything, no matter how
harmless in itself, which places an extra strain upon his vitality. At
the end of the day’s work he should rest quietly, preferably in the
open-air. Eight or ten hours’ sleep at night is a necessity. The most
critical time in a patient’s career is that which follows his return
from a sanatorium, and it is at this particular moment that the nurse’s
supervision and encouragement are so greatly needed.
=Light Work.= Many patients return from the sanatorium, unable to work
at their former occupation, yet sufficiently strong to do “light work,”
if such a thing can be found. In my experience, suitable “light work”
for these cases has yet to be discovered. We all know of patients who
have been given easy positions as night watchmen, elevator-men,
corridor-men, office work, gardening, and so forth, and who have done
well at such employment. The number of such positions, however, is so
small and so out of proportion to the number of those who seek such
occupation that it forms no adequate answer to the question; what light
work can we find for the arrested case? Our present industrial system,
which produces the class of people from which the consumptive is so
largely recruited, also fails to provide proper employment for him after
his so-called recovery. The pressure of this system makes it
sufficiently difficult for an able-bodied man or woman to find work that
pays, or even any work at all, but to find such work for the handicapped
is almost impossible. Light work means light pay, and light pay means an
insufficiency of food, clothing, and shelter, all three of which are
needed for the maintenance of health. In these days when the physically
fit cannot always earn a living wage, what chance has the poor
consumptive?
=Outdoor Work.= Another favourite fallacy is the advantage of outdoor
work for the returned patient. The sole value of outdoor work lies in
the opportunity to breathe fresh air, but this benefit may be more than
offset by the strain of long hours, exposure to heat, cold, and rain,
the lifting of heavy weights, and so forth. All these objections apply
to farm-work, driving delivery or freight waggons, the occupation of
motorman, conductor, and so forth. Now and then, patients undertake work
of this character and do well at it, but we cannot but believe that this
is in spite, of, rather than because of, their occupation.
In summing up the nurse’s value to these discharged cases, we find her
able to give immense assistance at a most crucial period in the
patient’s life. By this help and advice, she can often prevent his
relapse, or at least delay it for a long time. Her supervision provides
incentive and encouragement, and her careful watchfulness, both of the
patient and his household, is of value in detecting further danger
signals. If, as too often happens, he is eventually swept under by
currents too strong for him, she is still on the spot, tried counsellor
and friend, to make safer and easier the downward path.