CHAPTER IV
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.
[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.