CHAPTER II
ESTABLISHING THE NURSING SERVICE
When I first entered the training-school my outpourings to the superintendent,—a woman touched with a genius for sympathy,—my youthful heroics, and my vow to “nurse the poor” were met with what I deemed vague reference to the “Mission.” Afterwards when I sought guidance I found that in New York the visiting (or district) nurse was accessible only through sectarian organizations or the free dispensary.
As our plan crystallized my friend and I were certain that a system for nursing the sick in their homes could not be firmly established unless certain fundamental social facts were recognized. We tried to imagine how loved ones for whom we might be solicitous would react were they in the place of the patients whom we hoped to serve. With time, experience, and the stimulus of creative minds our technique and administrative methods have naturally improved, but this test gave us vision to establish certain principles, whose soundness has been proved during the growth of the service.
We perceived that it was undesirable to condition the nurse’s service upon the actual or potential connection of the patient with a religious institution or free dispensary, or to have the nurse assigned to the exclusive use of one physician, and we planned to create a service on terms most considerate of the dignity and independence of the patients. We felt that the nursing of the sick in their homes should be undertaken seriously and adequately; that instruction should be incidental and not the primary consideration; that the etiquette, so far as doctor and patient were concerned, should be analogous to the established system of private nursing; that the nurse should be as ready to respond to calls from the people themselves as to calls from physicians; that she should accept calls from all physicians, and with no more red-tape or formality than if she were to remain with one patient continuously.
The new basis of the visiting-nurse service which we thus inaugurated reacted almost immediately upon the relationship of the nurse to the patient, reversing the position the nurse had formerly held. Chagrin at having the neighbors see in her an agent whose presence proclaimed the family’s poverty or its failure to give adequate care to its sick member was changed to the gratifying consciousness that her presence, in conjunction with that of the doctor, “private” or “Lodge,”[1] proclaimed the family’s liberality and anxiety to do everything possible for the sufferer. For the exposure of poverty is a great humiliation to people who are trying to maintain a foothold in society for themselves and their families.
My colleague and I realized that there were large numbers of people who could not, or would not, avail themselves of the hospitals. It was estimated that ninety per cent. of the sick people in cities were sick at home,—an estimate which has been corroborated (1913-14) by the investigation of the Committee of Inquiry into the Departments of Health, Charities, and Bellevue and Allied Hospitals of New York,—and a humanitarian civilization demanded that something of the nursing care given in hospitals should be accorded to sick people in their homes.
THE NURSE IN THE TENEMENT
Ninety per cent. of the sick of the city remain at home
We decided that fees should be charged when people could pay. It was interesting to discover that, although nominal in amount compared with the cost of the service, these fees represented a much larger proportion of the wage in the case of the ordinary worker who paid for the hourly service than did the fee paid by a man with a salary of $5,000, who engaged the full time of the nurse. Our plan, we reasoned, was analogous to the custom of “private” hospitals, which give free treatment or charge according to the resources of the ward patients. Both private hospitals and visiting nursing are thereby lifted out of “charity” as comprehended by the people.
We felt that for economic reasons valuable and expensive hospital space should be saved for those for whom the hospital treatment is necessary; and an obvious social consideration was that many people, particularly women, cannot leave their homes without imperiling, or sometimes destroying, the home itself.
Almost immediately we found patients who needed care, and doctors ready to accept our services with probably the least amount of friction possible under the circumstances; for those doctors who had not been internes in the hospitals were unfamiliar with the trained nurse, whose work was little known at that time outside the hospitals and the homes of the well-to-do.
Despite the neighborhood’s friendliness, however, we struggled, not only with poverty and disease, but with the traditional fate of the pioneer: in many cases we encountered the inevitable opposition which the unusual must arouse. It seems almost ungracious to relate some of our first experiences with doctors. No one can give greater tribute than do the nurses of the settlement to the generosity of physicians and surgeons when we recall how often paying patients were set aside for more urgent non-paying ones; the counsel freely given from the highest for the lowliest; the eager readiness to respond. Occasionally sage advice came from a veteran who knew the people well and lamented the economic pressure which at times involved, to their spiritual disaster, doctors as well as patients.
The first day on which we set out to discover the sick who might need a nurse, my comrade found a woman with high temperature in an airless room, more oppressive because of the fetid odor from the bed. Service with one of New York’s skilled specialists had trained the nurse well and she identified the symptoms immediately. “Yes, there was a Lodge doctor.—He had left a prescription.—He might come again.” With fine diplomacy an excuse was made to call upon the doctor and to assume that he would accept the nurse’s aid. My colleague presented her credentials and offered to accompany him to the case immediately, as she was “sure conditions must have changed since his last visit or he would doubtless have ordered” so-and-so,—suggesting the treatment the distinguished specialists were then using. He promised to go, and the nurse waited patiently for hours at the woman’s bedside. When he arrived he pooh-poohed and said, “Nothing doing.” We had ascertained the financial condition of the family from the evidence of the empty push-cart and the fact that the fish-peddler was not in the market with his merchandise. Five dollars was loaned that night to purchase stock next day.
My comrade and I decided to visit the patient early the next morning, to mingle judgments on what action could be taken in this serious illness with due respect to established etiquette. When we arrived, the Lodge doctor and a “Professor” (a consultant) were in the sickroom, and our five dollars, left for fish, was in their possession. Cigarettes in mouths and hats on heads, they were questioning husband and wife, and only Dickens could have done justice to the scene. We were not too timid to allude to the poverty and the source of the fee, and felt free when we were told to “go ahead and do anything you like.” That permission we acted upon instantly and received, over the telephone, authority from the distinguished specialist to get to work. We were prudent enough to report the authority and treatment given, with solemn etiquette, to the physician in attendance, who in turn congratulated us on having helped him to save a life!
Not all our encounters with this class of practitioner were fruitful of benefit to their patients. Heartbreaking was the tragedy of Samuel, the twenty-one-year-old carpenter, and Ida, his bride. They had been boy and girl sweethearts in Poland, and the coming to America, the preparation of the clean two-roomed home, the expectation of the baby, made a pretty story which should have had happy succeeding chapters, the start was so good. Samuel knocked at our door, incoherent in his fright, but we were fast accustoming ourselves to recognize danger-signals, and I at once followed him to the top floor of his tenement.
Plain to see, Ida was dying. The midwife said she had done all she could, but she was obviously frightened. “No one could have done any better,” she insisted, “not any doctor”; but she had called one and he had left the woman lacerated and agonizing because the expected fee had been paid only in part. It was Samuel’s last dollar. The septic woman could only be sent to the city hospital. The ambulance surgeon was persuaded to let the boy husband ride with her, and he remained at the hospital until she and the baby died a few hours later.
Here my comrade and I came against the stone wall of professional etiquette. It seemed as if public sentiment ought to be directed by the doctors themselves against such practices, but although I finally called upon one of the high-minded and distinguished men who had signed the diploma of the offending doctor, I could not get reproof administered, and my ardor for arousing public indignation in the profession was chilled. Later, when I heard protests from employers against insistence by labor organizations on the closed shop, it occurred to me that they failed to recognize analogies in the professional etiquette which conventional society has long accepted.
However, many friendly strong bonds were made and have been sustained with a large majority of the doctors during all the years of our service. We have mutual ties of personal and community interests, and work together as comrades; the practitioners with high standards for themselves and ideals for their sacred profession comprehend our common cause and strengthen our hands. It is rare now, although at first it was very frequent, that the physician who has called in the nurse for his patient demands her withdrawal when he himself has been dismissed. He has come to see that although the nurse exerts her influence to preserve his prestige, for the patient’s sake as well as his own, nevertheless, emotional people, unaccustomed to the settled relation of the family doctor, may and often do change physicians from six to ten times in the course of one illness. The nurse, however, may remain at the bedside throughout all vicissitudes.
The most definite protest against the newer relationship came from a woman active in many public movements, who was a stickler for the orthodox method of procuring a visiting nurse only through the doctor. To illustrate the importance of freedom for the patients, I cited the case of the L⸺ family. A neighbor had called for aid. “Some kind of an awful catching sickness on the same floor I live on, to the right, front,” she whispered. A worn and haggard woman was lifting a heavy boiler filled with “wash” from the stove when I entered; on the floor in the other room three little children lay ill with typhoid fever, one of them with meningitis. The feather pillows, most precious possession, had been pawned to pay the doctor. The father dared not leave the shop, for money was needed, and all that he earned was far from enough. The mother, when questioned as to the delay in sending for nursing help, said that the doctor had frightened her from doing so by telling her that, if a nurse came, the children would surely be sent to the hospital. No disinfectant was found in the house, and the mother declared that no instructions had been given her.
The nurse who took possession of the sickroom refrained from mentioning the hospital; but when the mother saw the skilled ministration, and the tired father, on his return from work, watched the deft feeding of the unconscious child, they awoke to their limitations. The poor, unskilled woman, bent with fatigue, then exclaimed, “O God, is that what I should have been doing for my babies?” When the nurse was about to leave them for the night the parents clung to her and asked her if a hospital would do as much as she had done. “More, much more, I hope,” she said. “I cannot give here what the little ones need.” Late at night three carriages started for the children’s ward of the hospital; the father, the mother, the nurse, each with a patient across the seat of the carriage.
Said the critic when I had finished my story: “I think the nurse should have asked permission of their doctor before she granted the request of the parents.”
All the social agencies combined have not been able to dislodge permanently the quack who preys upon ignorance and superstition. One day a teacher in a nearby school asked us to visit a pupil who was highly excited and uncontrollable. The mother, when questioned, confessed that she had employed the “witch doctor” to exorcise the devil, who, he said, had taken possession of the girl. In our efforts to free the girl from this man’s control I invoked the aid of the parish priest, suggesting that his powers were being usurped. The County Medical Society finally secured conviction of the “doctor” on the charge of practicing without a license.
In the Italian quarter this species still preys upon the superstitious fears of some of the people, and the secrecy involved in his “treatment” makes permanent riddance extremely difficult. The people on the whole, however, give remarkable response to the “American” custom of employing a regular practitioner and the visiting nurse.
In this country, unfortunately, we have little data on morbidity. Statisticians desirous of obtaining figures for study have found interesting material in our files, and it has been possible to make comparison of the results of hospital and home treatment. Those who are familiar with the discussion upon papers presented by children’s specialists in recent conferences on the saving of child life have had their attention drawn to the disadvantage of institutional treatment. Discussion of this subject is recent, and the laity do not always know that certain complications incident to the hospital care of children are obviated by keeping them at home. Among these are cross-infections, while the high mortality among infants in hospitals has long been recognized and deplored as unavoidable.
We soon found that children’s diseases, particularly those of brief duration, lent themselves most advantageously to home treatment. Our records show that in 1914 the Henry Street staff cared for 3,535 cases of pneumonia of all ages, with a mortality rate of 8.05 per cent. For purposes of comparison four large New York hospitals gave us their records of pneumonia during the same period. Their combined figures totaled 1,612, with a mortality rate of 31.2 per cent. Among children under two—the age most susceptible to unfortunate termination of this disorder—the mortality rate from pneumonia in one hospital was 51 per cent., and the average of the four was 38 per cent., while among those of a corresponding age cared for by our nurses it was 9.3 per cent.
Doctors and nurses highly trained in hospital routine are apt to be hospital propagandists until they learn by experience that there is justification for the resistance, on the part of mothers, to the removal of their children to institutions, and that even in homes which, at first glance, it seems impossible to organize in accordance with sickroom standards, the little patients’ chances for recovery are better than when sent away. Diseases requiring climatic or operative treatment, or peculiar apparatus, must usually be excluded from home care.
In a letter written to a friend more than twenty years ago I find this account of one of our patients:
“Peter had pneumonia, complicated with whooping-cough. He is a beautiful yellow-haired boy, and even if the hospital could have admitted him, or his mother would have agreed to his removal (which she wouldn’t), I should not have liked to send him. The sense of responsibility for the sick child seemed a force that could not be spared for rousing an erring father. He is, apparently, devoted to the child, but had been drinking, and there was not a dollar in the house. The child, desperately ill, clung to him, calling upon him with endearing names. During the illness he worked all day (he is a driver) and sat up all night, and I think he will never forget his shame and remorse. The doctor had ordered bath treatments every two hours. These I gave until eight o’clock and the mother continued them after my last visit, but when the temperature was highest she was worn out, and active night-nursing seemed imperative. This Miss S⸺ willingly undertook—a service more difficult than appears in the mere telling, for the vermin in these old houses are horribly active at night, and this sweet girl ended her first vigil with neck and face inflamed from bites. Yet the people themselves were clean, and in this were not blameworthy. There is nothing harder to endure than to watch by a night sick-bed in these old, worn houses and see the crawling creatures and the babes so accustomed to them that their sleep is scarcely disturbed. Peter has had a beautiful recovery, rewarding his nurses by a most satisfactory return to a normal state of good health.”
Convalescent Home—“The Rest.”
The staff, which in the beginning consisted of two nurses, my friend and myself, has been increased until it is now large enough to answer calls from the sick anywhere in the boroughs of Manhattan and the Bronx, and the calls in the year 1913-14 came from nearly 1,100 more patients than the combined total of those treated during the same period in three of the large hospitals in New York—a comparison valuable chiefly as measuring the growing demand of the sick for the visiting nurse.
The service, though covering so wide a territory, is capable of control and supervision. The division into districts, with separate staffs for contagious and obstetrical cases, may be compared to the hospital division into wards. Like the hospital, it has a system of bedside notes, case records, and an established etiquette between physicians, nurses, and patients. Those that can best be cared for in the hospitals are sent there, the sifting process being accomplished by the doctors and nurses working together. Approximately ten per cent. of our patients are sent to the hospitals.
Serious nurses are gratified that the former casual and almost sentimental attitude of the public toward them and their work has been replaced by a demand for standards of efficiency.
Enthusiasm, health, and uncommon good sense on the part of the nurse are essential, for without the vision of the importance of their task they could not long endure the endless stair-climbing, the weight of the bag, and the pulls upon their emotions.
There has been an extraordinary development of the visiting-nurse service throughout the country since we began our rounds, and the practical arguments for sustaining such work would seem irresistible. It requires imagination, however, to visualize the steady, competent, continuous routine so quietly performed, unseen by the public, and its financial support is the more precarious because there can be no public reminder of its existence by impressive buildings and monuments of marble.