In these informal clinics considerable trouble is often caused by patients who arrive just before closing time, and expect to be examined. It is unwise to encourage this sort of tardiness, and a time limit should be set and strictly adhered to. All patients arriving after a specified hour should be directed to come another day, except such patients as are recognized by the nurse as worthy of exception from this rule. The most frequent offenders are not the patients who come from a distance, but those who live just around the corner. Unless punctuality be insisted upon, there will be endless overtime work for both doctor and nurse.
Tuberculin Classes. At some of the large dispensaries, selected cases are formed into what are called Tuberculin Classes, and given special treatment. These patients are very carefully chosen, both from a financial as well as a physical standpoint, and intensive work, of a curative rather than a preventive nature, is put upon them. The treatment is carried out in their homes, where as nearly as possible sanatorium conditions are attained. Unruliness, or failure to comply with the regulations, means being dropped from the class. These patients live on a carefully planned routine, carried out under close supervision of both doctor and nurse. They report to the dispensary at certain intervals, once a week or so, and there tuberculin is administered, weights taken, and examinations made. Each patient keeps a little book containing a daily record of his doings, including the number of hours spent in the open-air, food—kind and amount, exercise, temperature, cough, and other symptoms. This book is presented at each visit to the dispensary, and the nurse also inspects it when she visits his home. These class patients often do extremely well, and excellent results are often obtained. Like all work of a curative nature, however,—in which the subjects are carefully selected and as carefully rejected,—it deals with so few people that it makes no real impression on the situation. The tuberculosis problem is, what can be done for a thousand patients, not for twenty. It is always possible to select a handful of cases and maintain them indefinitely at a high level of health, by a considerable outlay of money, energy, and time—an expenditure from which the community as a whole derives little benefit.
To establish a tuberculin class is purely a physician’s affair, and all directions in regard to it come from the doctor himself.
The Nurse in Home and Dispensary. When the staff is large and there are several nurses, it may seem advisable, upon first consideration, to assign one nurse solely to dispensary duty, and leave the others to work in the homes. It is a better plan, however, to let all the nurses combine service of both kinds, as the single nurse in the small community must do. The intimate connection between home and dispensary should never be broken—it is much too valuable. Moreover, as far as the nurse herself is concerned, the monotony of dispensary work becomes extremely wearing, and it is well to vary it with duty in the home. It is a regrettable fact that a nurse confined to mere mechanical routine, is apt to lose that fine understanding and sympathy which she needs in her work, and which is always lost whenever human beings become merely “cases.”
In Baltimore this service is arranged in the following manner: There are three Municipal Dispensaries, and one other clinic, managed on the same lines, although not connected with the Health Department. These are situated at the boundary lines of two or more adjoining districts, and are thus accessible to the patients as well as the nurses of the adjacent areas. All four clinics are served by certain nurses of the Health Department, who are on duty on alternate days or alternate weeks, as the case may be. Thus, the nurse from any one district is on dispensary duty for two afternoons a week, every other week. This deprives the home of her services to only a very slight extent—a deprivation which is counter-balanced by her increased opportunities for effective work. We should never advocate any greater curtailment of home work, however, since the home, or centre of infection, is always the chief point of attack.
From another standpoint it is well that the nurses combine both kinds of service. Through sickness or other reasons, it may become necessary to substitute one nurse for another, and it is an advantage to have nurses trained and able to relieve each other when necessary.
The Nurse as an Asset to the Community. We have hitherto considered the nurse as a public health nurse, or servant of the entire community. Whether supported by public or private funds, whether connected with the Health Department or a private association, we have considered her as ready to answer all calls made upon her. We have regarded her as at the service of all physicians, dispensaries, institutions, social workers, and laymen, ready to respond to all calls without hesitation or discrimination. Her unattachment to any claims but those of the community as a whole gives her this broad field.
If, however, her work be limited to the patients of any one institution, association, or sect, she is no longer an asset to the community. For example, if she is employed by a certain dispensary to visit its patients only, her work is circumscribed. Her usefulness will be restricted—her service will be valuable to the physicians of such an institution, and she will collect data for their records, but her duties will be localized for the good of the dispensary, rather than for society as a whole. The same would be true if she be employed by a St. Vincent de Paul Society to care for Catholic consumptives, or by a Jewish organization to follow up Jewish patients—any arrangement through which she visits one patient in a block, but refuses the case next door, means a narrow field of service. She then becomes the nurse of an institution, or a sect, rather than a public health nurse. The object of her work is not the welfare of the community, but the welfare of certain individual patients. Incidentally, her work may benefit the community, but it falls far short of its possibilities. It must be supplemented by new agencies, with the consequent duplication and waste of effort that this always involves.
Our experience in Baltimore will illustrate this point. In 1904, when tuberculosis nursing was first organized, two nurses were placed in the field. One was attached to the dispensary, of the Johns Hopkins Hospital, the other placed in charge of the Visiting Nurse Association. Between them the city was divided into halves, one nurse working in the eastern, the other in the western portion of the town. The dispensary nurse visited only patients who had been to the dispensary. The nurse of the Visiting Nurse Association visited not only dispensary cases, but all patients reported from whatever source. Thus, in East Baltimore, if two consumptives lived in the same tenement, one a dispensary case and the other under no supervision at all, only one of these two was visited. In West Baltimore, both patients were cared for on equal terms. At the end of a year, another nurse was added to the Visiting Nurse Association staff, but not to the dispensary. The city was then redivided, this time into thirds, and again the patients were cared for under the same conditions. The dispensary nurse served the Johns Hopkins Dispensary; the Visiting Nurses served the dispensary and the community as well. Finally, in 1910, the tuberculosis work of the Visiting Nurse Association was taken over by the city, thus creating a new municipal department, the Tuberculosis Division of the City Health Department. At that time the dispensary nurse gave up visiting in the homes of the patients, and confined herself entirely to routine dispensary duties. This left all visiting work to the Health Department nurses, who were as punctilious in making reports to the dispensary as was the dispensary nurse herself. By this arrangement, the Phipps, in common with every other dispensary in the city, has had a large staff of nurses placed at its disposal. Both the dispensaries and the community gain through this co-operation.