VII.

Hospitals, Dispensaries, and Nursing.

THE WORK OF THE DISTRICT OR VISITING

NURSE.

BY MISS HARRIET FULMER,

SUPERINTENDENT OF NURSES, VISITING NURSE ASSOCIATION, CHICAGO.

The following is a short résumé of the system of the relief for the destitute sick in their own homes, carried on by the district or visiting nurse:

District or visiting nurse work covers that branch of nursing which cares for the sick poor in their own homes, when by reason of surrounding circumstances the patient may not be sent to the hospital. The work is likened to a large outdoor hospital, the various towns and localities being divided into wards or districts, the whole being responsible to the head or superintending nurse.

Philanthropic organizations providing skilled nursing care for the poor and the small wage-earners in their own homes have the advantage of having developed into such practical adjuncts to outdoor relief work among the poor that every small community is coming to look upon the organization of the visiting nurse system as a necessity. Its workings, if known and understood, must prove to the public its value in overcoming the great inadequacy of various sick relief agencies both of the county and city, caused often perhaps by lack of funds, many times unwisely and dishonestly spent. In its co-operation with kindred charities its workers are acknowledged and must be ever valuable agents in helping to place organized charity on the basis where modern effort would put it. The trained nurse as a visitor to the homes of the sick poor is unconsciously a living example of the well-worn Biblical saying, "I was

sick, and ye visited me." Her influence far outlives her actual presence, yet no class of charity workers see so quickly a response to their efforts as the visiting nurse. Daily instruction in habits of cleanliness and hygienic living to people in their own homes must some time bear fruit; and scarcely a week goes by that we do not hear from this and that quarter a story illustrating the effects of the personal contact of a woman skilled in this profession which belongs to her by reason of her birthright. Not long since one of these workers dropped in to pay a friendly visit to a family who not many months since had been patients. Here she found Tommy, a threeyear-old, yelling lustily because the little eight-year-old sister insisted upon giving him a bath, the child saying with an air of great responsibility that she had promised the visiting nurse to keep herself and her whole family clean, but Tommy always behaved so badly she was getting very tired. This same little one was herself clean and tidy; and her mother has told us since that she is constantly preaching cleanliness as a guard against illness, not only to her own family, but to the neighbors as well. She has been dubbed "the little health officer" in the locality.

The need of sick relief work is always apparent. It requires little red tape and not much investigation. If a person is suffering from bodily ills, he is immediately "a case," no matter what condition. brought the illness. Can there be any disputing the fact that the poor dying consumptive in his own cottage needs the visit of a nurse to give him clean linen and a bath, as no one other than skilled hands could do? or that the poor little child the county institution sends home because the case is "chronic," or the unfortunate woman with a malignant cancer, that no hospital will admit, need such care? If this system of relief work to the sick poor ministered only to those whom hospitals could not take, it would have even then more than ample excuse for existence; but, when we find avenues untold for just such service, it must be without question a benefaction to the poor.

The one established principle of the work is to teach and to preach cleanliness and right living in the homes and to help the people bear the burden of caring.for their own sick rather than shifting the responsibility to an institution. Five per cent. of the cases in one society alone prove that having to care for a sick member of the family, with a nurse's advice and instruction, develops in the well members many a good quality, and places the responsibility of caring for their

own sick on the right shoulders. The policy of the Chicago Association is to teach by practical demonstration how to care for the sick and afterward to see that the lessons are carried out.

House to house nursing among the poor began in Germany. Then England took it up. It has been established in America fifteen years, but it is only within a period of five years that the work has been generally organized. At present there are fifty associations in America, employing about 140 nurses. The women employed are graduates of the large general nursing schools. In most instances the society is one of the organized charities of the city, though frequently the funds are contributed by a special club or circle. Each organization adapts itself to the special demands of the city or town, but the large general plans must be the same the world over. More and more, as time goes on, we see newer and improved methods of giving relief to needy families; but in this one branch, care of the sick in their homes, we do not see a field for a change in the methods. From first to last the care has been given by trained nurses. Since the system of visiting nursing has taken its place as one of the necessary divisions of organized philanthropy, it would seem that its workers would profit by the additional study for a few months of the various methods of other charity and relief associations. The next step in the right direction in the work in this country will be to establish a special post-graduate course for all nurses desiring to take up visiting nurse work, for too many nurses come into the work having little idea as to the requirements and demands; and during the period of perhaps their first year the organizations suffer by their lack of knowledge. In the near future the Chicago Association will establish a course of this kind where graduates from general training schools may take up and learn the work in a systematic way.

The same principle applies to the work in the visiting nurse system as in every other branch of organized charity. None but the best-trained and well-paid people should go into the field. It is the last place where makeshifts should be found. I believe that voluntary service may be glad service in some instances, but not in dealing with the morals and physical ills of unfortunate humanity. The management of the business and financial aid may be left to voluntary service, but the active workers should be taken from the ranks of those skilled not only in nursing, but in the practical work which goes for the all-round social betterment of the people.

In most organizations the visits of the nurse average from eight to twelve in one day, varying from a half hour to two hours each. A history of a typical day in a large society may not be amiss. The first visit was to a dying consumptive, where a bath and clean linen were given; the second, a bath and alcohol sponge to a man with typhoid fever; the third, dressing a varicose ulcer on the leg of a woman who makes wrappers all day long at forty cents per dozen; fifth, baths and clean linen to a family of five, all ill with typhoid fever, reported case to board of health, arranged to send patients to hospital, two hours' work required; sixth, maternity case, bathed mother and babe, received ten cents for services; seventh, took temperature and pulse of convalescing typhoid, arranged to send patient. to country; eighth, bath to mother and daughter, both ill with consumption, new case reported to health board; ninth, very sick babe, gave bath, furnished milk, and instructed mother, sent free doctor; tenth, man with locomotor ataxia, gave bath, made application to send patient to Home for Incurables.

Who, in hearing this, will deny that it was not a day full of satisfaction to the nurse, of practical benefit to the patients, and of infinite credit to the supporters of the work who make it possible that the relief may be given?

For the past ten years it has been clearly shown that the district visiting nurse work is the best means at the smallest cost of helping the conditions of the poor, sick or well. Hospitals do much good; but, after all, they offer but outside methods of education. It is by reaching the people in their own homes and teaching them to utilize, and make the best of what they have that lasting good may be accomplished.

In presenting the work of the charitable nursing service, I must be pardoned for seeming to cry my own wares; for this work perhaps appeals to its active workers as to no one else. The laity have only a vague idea of what the work is; for we have nothing tangible to show the public who contribute to its support,- no spacious hospitals surrounded with beautiful grounds that the patients never see; no beautifully furnished rooms in this or that institution, too handsome to be used by poor little John, the helpless paralytic from the little back basement room, whose only window looks on a garbage box; no white iron beds in the clean, well-furnished wards of a hospital, where poor Mrs. B. mayhap finds temporary care, only to

be removed again to her own filthy surroundings, physically helped, maybe, but not with the lasting good resulting, had the care been given her in her own environment. Hospitals may be God-sends to the people of certain classes; and, in answer to the question, Do they not give better and more adequate service? I answer, Yes, to the people who do not need teaching; but to the poor there is only one place to instruct and preach the law of health, and that is in their own surroundings. We are constantly crying that the home element is the basis of morality; and so this system of visiting nursing is making an effort to deal with the less fortunate in their own homes, and teaching the responsibility of one member of the family to the other, while giving practical lessons in cleanliness and care in their own surroundings. Who makes it possible that Mrs. B. who is ill may remain at home, to keep together her family of little ones, and that the father may still continue his day's labors? This system of visiting nursing. If this case should go to the hospital, the children to an institution, and the husband, mayhap, to a saloon, who is responsible for the wrong done, by even temporary dissolution of this family? I would not belittle hospitals. They are the greatest institutions of the day, but they do not and cannot give care to all cases. Consumption, cancer, rheumatism, paralysis, all need care; and yet there are not institutions enough for all these physical ailments. Who steps in to relieve the inadequacy? This same comparatively unknown visiting nurse, whose teaching helps the people. to demand of their landlords better housing. And so, indirectly, the visiting nurses help to solve the tenement-house problem, by arousing the poor themselves to ask for better quarters, and thus force the landlords to build better living places.

The public will search long before it will find so large a return for the money which it invests as in helping to send into the destitute homes of any locality, 365 days in the year, a corps of trained nurses to give the same skilled care that the rich may provide for themselves. Many people say, Why not give your revenue to a hospital, and let them give the care? What institution gives nursing and medical care, surgical dressings, and medicine for the sum of not quite 30 cents for the year, for each case? Last year the income of the Chicago Association was not quite $17,000, and the cases cared for numbered 5,915. Seven-eighths of these cases would not have been taken in any hospitals, for the remainder there was no room.