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.