CHAPTER XV
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.
[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.