Public health nursing

Front matter

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TEXTBOOKS ON PUBLIC HEALTH NURSING

Part I The Development Of Public Health Nursing

CHAPTER PAGE 1. History . ; : f : : : : . : : i 3 2. History, CiteRouy ‘ } , ! : : : : t Oh iAG 3. ForEIGN DEVELOPMENTS : , : : ; p , : ee Pe 4. FUNDAMENTAL PRINCIPLES . t ; j 4 3 ; é s 4 41 5. Moprern ProsiEMs . : f he G SEcTION 1. EDUCATION OF THE Paper Hatnen pears ; VAS Section 2. Private or Pusiic ConTRoL t ? : : 2% 69 Section 3. GENERALIZATION AND SPECIALIZATION. ! } bie SecTION 4. PROFESSIONAL RELATIONSHIPS . : : ‘ . 84 ART II

PUBLIC HEALTH NURSING UNDER PRIVATE AUSPICES

1. Srartmne a Pusuic HeattH Nursing ORGANIZATION , : PreTOr

2. PLAN OF ORGANIZATION . : ‘ : , : ‘ é ’ a eLO2

3. Tue Boarp oF MANAGERS . ! : y 4 é ‘ : anus PART III

PUBLIC HEALTH NURSING UNDER PUBLIC AUSPICES

2. County i ‘ : : Daan ; : ‘ i ; 40

3. MUNICIPALITY . ‘ i ; 4 , : : : : , Eubank thee PART IV

THE NURSING GROUP

1. Tue Nurse’s Pointor VIEw. . RM I its BEM i al OE Sergeant a A 8 2. Tue Srarr NurRSE . ; : : i ; d : : ; ee rg | 3. THe SUPERVISOR : : ; : ‘ é , : : i rae bows 4, Tue Carer EXECUTIVE . ; , ' ‘ ; : : t sue 5. Group MANAGEMENT : : , ; , : : wus 219 6. THe Purim, NursE— AND THE NEW Minae A : : 4 : oo Doe 7. Tue Nurse WorkKING ALONE ; ; : Be ch CE ek he OR eee vil vili CONTENTS

PART V SPECIAL BRANCHES OF PUBLIC HEALTH NURSING CHAPTER 3 PAGE 1. TUBERCULOSIS . : ; : : ‘ ; : ‘ : ( 26E 2. ‘TUBERCULOSIS, Covina bg EES aR hk oS ohne tne eke Ma eee 3. CHILD WELFARE. . CPOE i TNR KT eT 4. Curitp WELFARE, Cuevas ‘ : 4 : : i “ , paar | 5 ScHOoo.u. , 5 H 4 : : . ; i : rey 49) 6. MENTAL Hicpess ’ ; f : ; : 3 3 4 ‘ . 343 7. INDUSTRIAL ; : i ; : ; i : a : . 360 8. VENEREAL DISEASE . : : ; ; : A tire. . 378 PART VI RECORDS AND STATISTICS 1. ReEcORDS AND STATISTICS . fk , ; ‘ a : ot a a eee APPENDIX

1. CHRONOLOGY . : ; : . 409 2. NATIONAL ciate teria FOR Dirvtc Elvidacies Noneiea ; : 4123 3. RED Cross Pustic HeattuH NursinG SERVICE . : { : Mer > 4. NatrionsaLt Heauru Counciu . ‘ 420 5. CoNCLUSIONS OF THE COMMITTEE FOR THE Saupe OF ‘Nowsee

EDUCATION . , . : , , : , : : . oo 4a

Preface To Second Edition

Tue first edition of this book was written during the early years of the war, and was published in 1916. Since its publication the United States has had her own war experience, and following the armistice has passed through six years of great and unprecedented change and adjustment. Any book on public health nursing that fails to take account of the effect of these years on the health movement must fall short of its purpose in representing present-day opinion.

Revision at first seemed a simple matter, a question principally of amplification and correction. In proceeding, however, it became evident that something far more radical was necessary if true expression was to be given to modern trends of thought. Though eight years ago the public health nursing movement had emerged _ from its pioneer stage of development and was at a point where rapid growth was to be expected, the war, bringing as it did new knowledge of actual health conditions through the draft figures, and a new conception of the importance of national health, greatly accelerated the speed of normal growth and at the same time changed the emphasis on many points. It is this change of emphasis that has made a mere revision of the earlier book impossible, and has necessitated a complete rewriting.

In the preface of the first edition the statement is made that if the then rapid development of public health nursing continued it was probable that much contained in its pages would be of value chiefly as showing the lines of thought leading to later conclusions. This prediction has proved both true and untrue. There has been in these eight years no complete overthrow of once accepted principles and no radical change of method. Rather there has been a development of ideas clearly indicated before 1916, but necessitating a shifting of emphasis of expression on every page. New points of view regarding the educational preparation of the nurse and the value of an educative supervision of her work, the establishment of county health units x PREFACE TO SECOND EDITION with a vast increase in rural nursing, the growing appreciation of the function of the nurse as a teacher, the new importance attached to work with children, the introduction of health education into the schools, the development of the nurse herself in a wider sphere of usefulness; these and other changes of emphasis have produced not only new ways of thinking, but in many instances a new technique, and their effect is to be felt in every part of the work.

In rewriting the book its construction has necessarily been somewhat changed, and eight new chapters have been added. One chapter, that on hospital social service, has, after some hesitation, been omitted, in the belief that this subject should find a place in a book on social work rather than in one on public health nursing.

Certain questions of nomenclature have arisen, chief among them the name to be given to the nurse and to her work as described in these pages. In view of the present tendency toward more generalized methods of administration, and also because the functions of the various nurses are now so closely interwoven, the names ‘visiting nurse” and “visiting nursing association” have not been used in this book. ‘Public health nurse” and “public health nursing” have been substituted throughout to describe all types of nurses and organizations.

No one realizes more fully than the author the impossibility of dealing adequately with a subject so large as public health nursing within the limits of a single book, or from the point of view of a single individual. There has seemed, however, a place for a book containing at least an outline of the subject as a whole, in which relationships might be studied and the continuity of events followed. The author has sought counsel and advice from many people whose knowledge in their various fields far exceeds her own. It is impossible to name all of those who have contributed in this way, but grateful acknowledgment is especially due to the following men and women, first to her brother, Hon. Charles T. Davis; to Miss Katherine Tucker, Superintendent of the Philadelphia Visiting Nurse Society; to Miss Ella Phillips Crandall, Associate General Executive of the American Child Health Association; to Miss Gertrude E. Hodgman, Educational Director, National Organization for Public

PREFACE TO SECOND EDITION xi

Health Nursing; to Miss Elmira W. Bears, Secretary for School Nursing of the National Organization for Public Health Nursing (acting as Nursing Division of the American Child Health Association); to Miss Alice Fitzgerald, Former Director, Nursing Department of the League of Red Cross Societies; to Miss Elizabeth G. Fox, Director Public Health Nursing Service of the American Red Cross; to Miss Anne A. Stevens, General Director of the National Organization for Public Health Nursing; to Miss Grace L. Anderson, Director East Harlem Health Demonstration; to Miss Margaret K. Stack, Director Bureau Public Health Nursing, Connecticut State Department of Health; to Miss Mary Elderkin, Chairman, Nursing Committee, National Organization for Public Health Nursing; to Miss Alice Hall, Public Health Nurse, Thomasville, Georgia; to Miss Mary E. Edgecomb, Director, Public Health Nursing Organization, Englewood, New Jersey; to Miss Helen Falvey, Supervisor, Child Welfare Service, Providence District Nursing Association; to Miss Agnes G. Talcott, Superintendent of Nurses, Bureau of Municipal Nursing, Los Angeles; to Mrs. Mary Lippincott, Head Nurse, Venereal Disease Service, Providence District Nursing Association; to Miss Winifred L. Fitzpatrick, Associate Director, Providence District Nursing Association; to Miss Emily Diman; to Miss Eleanor B. Green; to Mrs. Harry P. Cross; to Dr. Arthur H. Ruggles, Superintendent, Butler Hospital, Providence; to Dr. James A. Myers, Assistant Professor, Department of Preventive Medicine and Public Health, University of Minnesota; and particularly to Miss Ada M. Carr, Editor of the Public Health Nurse; also to Miss Edith 8. Walker, for helpful secretarial assistance.

Introduction

TuHose who have been watching the evolution of our old friend the District Nurse through various stages into the Public Health Nurse will probably have noted how closely this growth has been identified with the sanitary and medical advances which have brought forth the modern public health movement. They will therefore have realized that the rapid expansion of health nursing is due not purely to philanthropic impulse, but that it rests upon the solid and stable ground of a well-recognized and permanent social necessity.

They have probably seen how, as the public health movement has grown, it has addressed itself to the more pressing problems of the moment, concentrating its efforts first upon one menacing disease or condition and then upon another, building up machinery to be maintained for their control and ultimate prevention, and then passing on to occupy new fields of activity, and ever sweeping forward with steadily growing impetus. Thus it has devoted itself successively and continuously to the problems of tuberculosis, of the health of school children, of the study and prevention of infant mortality, of the study and prevention of insanity, of the control of venereal, of occupational, and of other diseases; and the interested observer can hardly have failed to note how at the very heart and center of these various efforts has usually been placed the work which nurses, and they alone at present, are prepared to give. In varying capacities nurses have become an integral part of the whole public health movement, so essential and indispensable indeed to the working out of its manifold problems that it appears to be generally understood and accepted that adequate health measures can now neither be established nor maintained without that peculiar kind of cooperation which nurses’ training enables them to give. The public health movement had to forge no new instrument for this task; it found an almost perfect one, keen, flexible and potentially mighty, already available in the field. It is not a

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XIV INTRODUCTION far cry from the District Nurse, working and teaching in the homes of the sick and poor and helpless, to the Public Health Nurse who reaches the home by way of the city health department, the public school, the factory or store. It is really a rational and logical step, for medical science has as yet found no better way to speak than through the voice and the personal ministrations of the visiting nurse, no more strategic point of attack than the homes in which she works, no more important factor in the spread of disease than the individuals who are the objects of her constant care and solicitude. With the behavior of these individuals, with their hygienic conduct as it were, public health, it seems, must unceasingly concern itself.

The development and status therefore of public health nursing appear to emerge as a matter of vital public interest, and Miss Gardner has performed an important service in placing at our disposal the first really comprehensive presentation of so timely a subject. From the depths not only of a rich experience preceded by a careful training, but of an unusual understanding of, and respect for, human relationships, she brings forth the mature wisdom which characterizes the book. She is wise in her counsel, wise in her suggestions, wise in her omissions.

It is not only interesting but important for us to know how this work has grown to its present coherence of effort, how it established its field, found its tools and formulated its method; what traditions have been discarded and why, and which there has seemed justification for preserving. The thousands of nurses now at work in this field, the older ones who have blazed their own paths, the younger ones who are just at the starting point, will greatly value these results of acute, accurate and prolonged observation; the careful analysis of typical situations in which small things are neither overlooked nor overestimated, the thoughtful discussions of the many extraordinary relationships which nurses in this work have to sustain and pass on unweakened to their successors, the clear and frequent presentation of the imperative necessity for wide cooperation with others.

Miss Gardner knows her subject from within—every stage of it. For that, the supervisor and the staff nurse will be equally grateful. And she sees it from without as her handlimg of the important (and infrequently approached) subject, “The Board

INTRODUCTION XV of Managers,” admirably shows. She reveals herself as a woman of quite exceptional administrative insight. Seen through her eyes complex situations become clarified, difficulties dissolve, things settle into their places and the work moves easily to accomplishment along well-directed lines, the shaping of practical work to the fulfilling of a vision,

“With great things charged he shall not hold Aloof till great occasion rise,

But serve, full harnessed, as of old

The days that are the destinies.”

But marked as have been the recent advances in this work, and devoted as are its workers, we know that we are as yet but touching the fringe of our great public health problem. In no field in the world is the need at present greater and nowhere is there offered a wider variety of opportunity to render services which are both greatly needed and humanly interesting and satisfying. Not only to those who have already set their hands to this urgent task, and prepared themselves to really help the world by arduous training for its service, but to the very large eroup of women of liberal education and good upbringing who are anxious to serve but not yet willing to prepare themselves to do so, should Miss Gardner’s book appeal. A contribution indeed to the literature of nursing and of service has this valuable public servant of the city of Providence made.

M. ApELAIDE NuTTING, Director, Department of Nursing and Health, Teachers College, Columbia University, New York City.

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PART I

THE DEVELOPMENT OF PUBLIC HEALTH NURSING

Chapter 1 History Of The Public Health Nursing Movement

On the foundation of a long tradition of self-sacrifice is being built the present structure of public health nursing, the latest development of modern nursing work.

Most movements are developments, not creations, but few have their roots so directly planted in a past filled with inspiration. In that past, skill, as we understand it now, was often lacking because the requisite knowledge to produce the skill did not exist, but a spirit of service was the motive power, and unless that spirit remains, the modern movement, with all its knowledge and all its skill, will have lost more than it will have gained.

Nursing, like so many other things the history of which may be studied from century to century, has had its ups and downs, its bright periods of inspired effort, and its black periods of temporary degradation. Because we have so lately emerged from such a black period, we do not always look beyond to what has gone before.

It is not to the Sairey Gamps and Mrs. Harrises that the ancestry of the modern nurse is to be traced. Sairey was but an unhappy incident in the history of nursing, and the ancestors of the modern nurse are the noble Abbesses and early Christian women who were trying to do for their day and generation what the nurse of today is trying to do for hers.

Visiting nursing, the care of the sick in their homes by those who make such work their business, has undoubtedly existed in almost all ages. When we read of the care given the sick in the centuries before Christ in such enlightened countries as India, Egypt, Greece, and in Rome, we cannot believe that this care was strictly confined to the hospitals. Visiting. the sick is not only spoken of in the New Testament as one of the forms of charity, but long before the Christian era the Rabbis declared it to be incumbent on every Jew ‘‘to visit the sick, in order to show them sympathy, to cheer and aid and relieve them in their suffering,’ and since the founding of the primitive Church, such work has been a recognized part of its activity.

Deaconesses, Widows, Nuns, and Sisters all consecrated their lives to nursing work, and even from the first few centuries authentic accounts of the work of individual women have come down to us. Perhaps the first visiting nurse whom we know by name was Phebe, who, St. Paul said. “hath been a succorer of many and of myself also.”

With the rise of Monasticism came more concerted action for the care of the sick. Those who have visited the Benedictine Monastery founded by St. Benedict in the sixth century, perched on its hill at Monte Casino, cannot but be impressed with the many ways in which the modern settlement idea resembles this community life, with its numberless activities for the good of the people, among which nursing the sick was one of the most important.

For centuries the monasteries and convents stood for all that was then best in nursing, and we of a later generation, who have lived to see the rise of a great secular profession, should not forget that it would have fared ill indeed with nursing if it had not been for the monks and nuns of the middle ages. Without the protection of the strong arm of the Church, individual effort would probably have perished in those stormy times, even if such effort could have found expression in other ways or received its inspiration from other sources.

From the Crusades sprang the military nursing orders; and prominent among them was the order of St. John of Jerusalem, the same order which eight centuries later (in 1874) we find instituting an investigation of district nursing in England.

During the latter part of the eleventh century new nursing orders sprang up outside the Church, though later in most instances these secular orders either voluntarily or involuntarily bowed to the demands of the Church and placed themselves strictly under her control.

*, Nutting and Dock, “History of Nursing.”

Nursing was an important branch of the work of the Beguines, an order which at the beginning of the fourth century is said to have numbered two hundred thousand women working in Belgium, France, Germany and Switzerland, an order which made a most determined effort to maintain its freedom, and independence of ecclesiastical control.?

The Sisterhood of the Common Life was essentially an order of visiting nursing, while the more important order of the Santo Spirito seems to have nursed its sick in hospitals.

All through the middle ages these nursing orders existed, many of them tertiary orders, some of them for men, some for women, some for both men and women, and in them the high born and rich and those of lowly birth alike gave their services to the care of the sick. One woman of wealth and position, Mme. de Chantel of Dijon, grandmother of Mme. de Sévigné, at first joined no order, but gave her life to visiting nursing; she also took into her own home single patients who needed her constant care. After her husband’s death, with the help of St. Francis de Sale, she founded the Visiting Nursing Order of the Visitation of Mary. The rule was most simple, involving no vows of poverty, and its members were not cloistered but were “to visit the sick daily, bathe, dress and care for them, taking home their linen to be washed.” Unfortunately the decree passed by the Council of Trent in 1545, that every community of women should be enclosed, was a death-blow to visiting nursing work as done by the religious orders. After four short years of activity, the opposition of the Church to this unenclosed community became too strong, and the rule of the order was made over and the visiting nurse work given up.

In all the past, however, there is perhaps no more prominent figure in the history of public health nursing than that of St. Vincent de Paul, who, in the middle of the seventeenth century, with the help of Mlle. Le Gras, founded the world-famous order of the Sisters of Charity. A friend of Mme. de Chantel, he had seen the failure of her scheme of visiting nursing, and he was determined that the sisters should not become religious in the monastic sense—‘‘ Nuns,” he said, “must needs have a cloister, but the Sister

* Nutting and Dock, “History of Nursing.”

of Charity must go everywhere—no other monastery than the house of the sick, no other chapel than the parish church.” He knew in his wisdom that the work of a visiting nurse was incompatible with solemn vows, enclosures, hours of religious exercises and complete subordination to the clergy,? and he knew, too, many other things about visiting nursing. He recognized the necessity of instruction for the Sisters, and gave most excellent advice as to their relation to the physicians; while his knowledge of what we now call social work was so far ahead of his time that he may be said to have really founded the first charity organization on principles not so very unlike those accepted at the present time. His sane wise outlook and the example of his simple life of consecrated self-sacrifice, together with his remarkable power of organization, produced results too well known to require comment. Every public health nurse would do well to know by heart his beautiful description of the Sisters’ calling, for it is equally applicable to our modern nurse.

“Their convent must be the houses of the sick; their cell the chamber of suffering; their chapel the parish church; their cloister the streets of the city, or the wards of hospitals; in the place of the rule which binds nuns to the one enclosure there must be the general vow of obedience; the grating through which they speak must be the fear of God; the veil which shuts out the world must be holy modesty.”

We sadly need these bright spots, for in the latter part of the seventeenth century nursing entered upon the darkest period of its history. Though Sisters of Charity and Nuns were still in nominal charge of the sick in hospitals, they gave less and less personal care to the patients who were left for such care to the tender mercies of women totally unfit to bestow it.

As we read of the early history of nursing, of the work of St. Elizabeth of Hungary, of St. Catherine of Siena, of the secular orders of the Beguines and the Santo Spirito, and of the later religious orders, both Roman Catholic and Protestant, it seems almost incredible that nursing should have sunk to the level at which we find it in the middle of the nineteenth century, when modern secular nursing was brought to life by Florence

* Nutting and Dock, “History of Nursing.”

Nightingale, who in turn received her impetus from the Fliedner’s Training School for Deaconesses at Kaiserswert.

Even during this dark period good and devoted women were giving their lives to the relief of suffering, but it was only individual effort, and as a rule in every country the great body of the sick poor were being cared for by overworked, ignorant, and unprincipled women, while the sick rich fared but little better.

No dignity was attached to the office of nurse, and in many places no effort was made to obtain women of good character, as the duties were considered too disagreeable to attract the respectable. Even where nursing was nominally in the hands of Nuns and Sisters, little of the actual care of the sick was given by them personally.

This deplorable state of things was not wholly unrecognized, and there are in existence various reports published by doctors and others setting forth the situation. In one or two instances it was even arranged that some instruction should be given the hospital attendants, but no effort was made to secure the services of a higher type of woman, or to make living conditions or hours of work more reasonable.

Though nearly fifteen centuries earlier Roman ladies of patrician birth had devoted themselves to the care of the sick, and though their example has been followed at intervals throughout the history of nursing by those of wealth and social position, Florence Nightingale’s assertion that nursing was a work for gentlewomen fell like a bomb upon the people of England.

Outside the protected life of the cloister this seemed impossible. The wonder to us now is that work requiring the best that any woman has to give, should have been allowed to remain so long in the hands of those totally incapable of doing it. We can hardly conceive giving our sick to the care of drunkards and profligates, but it is only by realizing that this was the fate of the majority of sick people that we can comprehend what has been done for the world by the early pioneers of nursing reform, whose names and deeds should never be forgotten by those who follow comfortably in paths hewn out by them with such infinite effort.

Florence Nightingale’s contribution is known to every one, though, owing to her modesty and method of working through others, the remarkable work that she did from her sick bed during the long years of her invalidism has perhaps not always been recognized. The dramatic character of her work in the Crimea is so picturesque as to interest the whole world; but the thoughtful nurse would do well to study her later labors, for as prophetess and health teacher, she has no equal. In paying our tribute to Florence Nightingale, however, we must not forget to accord to Pastor Fliedner and to his two wives, Friedericke and Caroline, the honor that is so justly their due. The seed that later grew and developed into modern secular nursing was planted at Kaiserswert and it was there that Miss Nightingale went to study nursing methods. The deaconesses nursed the sick in hospitals, in private homes, and also did parish or district nursing, the training provided for them being systematic, though simple. The astonishing growth of the work of these Protestant deaconesses all over the world proved its need at the time, though later modern nursing conditions have somewhat changed the position of deaconesses as nurses.

Florence Nightingale did not, as many suppose, found the first school for nursing in England. Two others were established before the Nightingale School.t| Nor was she alone in her advanced views as to the better training of nurses. Sir Edward Cook in his life of Miss Nightingale says that the reason Florence Nightingale was the founder of modern nursing was because “she made public opinion perceive, and act upon the perception, that nursing was an art and must be raised to the status of a trained profession and that the means by which she achieved this great work were three, by her Example, her Precept and her Practice.”

We have touched upon the general nursing situation because it is necessary to realize what already existed in the middle of the nineteenth century before we can comprehend the Herculean task which was undertaken by Mr. William Rathbone of Liverpool when in the year 1859 he founded, with Florence Nightingale’s help, the first District Nursing Association in the modern sense of the word. |

He cannot, perhaps, be called the first pioneer, for in 1840 Mrs. Fry had made an effort to bring skilled care to the poor

*E. T. Cook, “Life of Florence Nightingale.”

in their own homes by the establishment of the Nursing Sisters of Devonshire Square in London,® and in 1848 there was founded the Society of St. John’s House, whose object was to raise the standard of nursing and to provide nurses for hospitals, for private cases and for the care of the sick poor in their homes.® Other Anglican Sisterhoods also included visiting nursing among their activities, though the Sisters undertaking it were usually ‘without any adequate training for nursing work.’ The Bible Women and Nurses’ Mission founded by Mrs. Ranyard in 1857 added its quota to the general effort toward the improvement of the physical condition of the poor, but nevertheless it is to Mr. Rathbone that we owe the first definitely formulated District Nursing Association, and in that sense he may be called the father of the present movement.

Owing to illness in his own family Mr. Rathbone had seen for himself the comfort brought to the sick by trained service. He therefore asked the nurse who had been in his own house to undertake as an experiment the care of the poor in their homes for three months. The nurse consented, but at the end of one month pleaded for release from the engagement, saying that she could not endure the misery with which she was brought in contact. After persuasion, however, she agreed to continue for the remaining two months, and so excellent was her report and so great her success in even this short time, that she begged to be permitted to go on, and Mr. Rathbone determined to establish a permanent system of district nursing work for Liverpool. |