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us never cease to insist on the importance of those things
which can be learned from the patient alone.

It is a truism that education of any kind fails of its true
purpose unless it is considered as a starting point for
further excursions into the field of knowledge. If the
student's interest can be aroused in the mere existence of
such problems as the family budget, the housing question,
school hygiene, probation, and the many other live issues
of the day, she will never be as she was before. If, in
addition to her own chosen line of work, she can be given
an acquaintance, gained from personal observation, with
school and tuberculosis nursing, with the work of shop,
factory, or hotel nurses, with hospital social service, with
mental hygiene work, or with the rapidly developing field
of infant welfare, door after door will have been opened
to her, and the key, at least, placed in her hand for fu-
ture use.

The success or failure of such education will depend
on the power of the educator to give this to the student,
not as a mere hodge podge of unrelated though interesting
information, but as closely related aspects of one vast sub-
ject which, in turn, has its own place in the general trend
of the day.

The increasing interest shown in public health nursing
education makes the prospect a bright one, for in the
better education of the public health nurse lies the surest
hope for the future of the whole movement.

The second major problem, that of municipal or state
control of public health nursing, is one affecting princi-


pally, though not exclusively, the various special branches
of the work.

In the past, public health nursing has almost every-
where been started as a private enterprise. Occasionally
there has been a municipal subsidy, but where this has
been the case it has rarely been granted until the value of
the work has been proved by private philanthropy. Even
the branches of the work now usually undertaken by
municipalities, such as school nursing or the care of the
tuberculous, were first demonstrated as successful experi-
ments by visiting nurse associations. There is undoubt-
edly at the present time a very general tendency in many
directions toward an increased assumption of responsi-
bility by both states and municipalities. Those who are
opposed to all such tendencies as paternalistic naturally ob-
ject to state or city control of public health nursing.
Other objections are more or less involved in local political
conditions, though there are certain inherent advantages
and disadvantages to both public and private administra-
tion of nursing work which may be briefly mentioned.

Public health nursing as undertaken by private initiative
has everywhere enlisted the interest of groups of men and
women who have performed their duties as a veritable
labour of love, bringing to them a spirit of devotion and
self-sacrifice which is of inestimable value. The with-
drawal of such a spirit from any movement could not fail
to be a matter of serious concern. The loss of elasticity
of methods under public administration is another, though
less serious consideration, while the danger of undue
political interference and the uncertainty attending the
question of appropriations are more or less important difi5-
culties as they are affected by the various local political

On the other hand, the fact cannot be ignored that much
good work is being retarded in its growth because of the
inability of private organisations to raise the funds neces-


sary for expansion. Due and primary emphasis sliould be
laid on the quality of public health nursing work, but the
quantity of it is also a matter of importance. It is not
enough that visiting nurse associations should look with
satisfaction on any limited accomplishment, ignoring be-
cause of financial impotence, unojDcned districts or unex-
plored fields of endeavour. Xor is it enough that a state
should point with pride to the well-developed public health
activities of its large cities. What of the hundreds of
square miles of farm lands or the countless small villages
where no provision for nursing care is made ?

If free public health nursing is a logical sequence to
free public school education, and there seems no very good
reason why it should not be, private enterprise must hold
itself in readiness to step aside, permitting state and
municipality to undertake and accomplish a task wholly
beyond its own financial powers. Xothing so extreme,
however, may be in store for public health nursing. It
seems more likely that there w411 be a continuance of the
present situation. Private organisations will continue
to inaugurate new work and maintain old work, and
municipalities will continue their responsibility for cer-
tain of the special branches, entering perhaps, new and
as yet unexplored paths while the state will concern itself
more and more with public health nursing in rural dis^
tricts through county organisations. What part the Fed-
eral Government may eventually take in the public health
nursing movement we do not know, though the establish-
ment of the Federal Children's Bureau foreshadows a
number of possibilities. That public health nursing is
being efficiently done by both municipalities and state
bodies is well known. Where a change of administration
has been made it has not infrequently been found that
some branches of the work formerly undertaken by private
organisations have been distinctly strengthened by the
authority of municipal control, while others placed imder


the state have gained by the uniformity of effort made
possible in the larger area.

The situation which exists at the present time in many
cities would seem a healthy and satisfactory one ; namely,
the existence of a vigorous visiting nurse association sup-
ported by private funds, and in addition a staff of city
nurses for school nursing, tuberculosis work, midwife
inspection or any of the other branches of the work
usually assumed by the municipality. The associa-
tion, with its greater independence of action, can go
before, inaugurating new methods, starting new spe-
cialties and setting a high standard of efficiency. When
the time is ripe for separation, the various well-tried
branches of the work may be turned over to the munici-
pality in good running order, together with the nurse or
nurses most familiar with their management.

In this way the private enterprise is financially freed
for new efforts, and the municipality is relieved of the dif-
ficulties of the experimental stages of its work. By the
exchange of nurses close co-operation is somewhat simpli-
fied, and the public health work of the city is conducted as
one big and important undertaking, without overlapping
or friction, and with an assurance of stability and perma-
nency, as well as elasticity and fostering attention, derived
from the dual nature of its existence.

The greatest safeguard against deterioration of publicly
administered work will be the continued interest of the
same men and women who were originally responsible for
it before city control was assumed. To this end nursing
bureaus or committees should be created.^ If the criti-

1 An Ordinance Creating a Bureau in the Health Department of
the City of Los Angeles to be known as the Bureau of Municipal
Nursing, providing for the appointment of a Commission, and fixing
its powers and duties.

The Mayor and Council of the City of Los Angeles do ordain as

Section 1. There is hereby created in the Health Department of


cism, so often meted out to municipal methods, can be re-
placed by sympathetic assistance, based on personal knowl-
edge of working conditions, from the same class of citizens
who are usually responsible for the work of visiting nurse
associations, there would not be that wide gulf sometimes
noticeable between the two branches of the same activity.

That many an intelligent and interested director of a
well-managed visiting nurse association is totally unin-
formed of the progress of public health work as done by
his own municipality is a recognised fact, and but indicates
an attitude of mind too well known to require comment.
If, however, we are to permit and even encourage a tend-
ency toward an increased assumption of responsibility by
state and municipality the fact must be recognised that
individual responsibility ought to be thereby increased,
not lessened, for what is the state and what is the city but
an aggregate of individuals on each one of whom whether
they wish it or not is bestowed the moral responsibility of

The third problem, that of the advisability of specialisa-
tion in nursing, is one about which there is gTeat difference

the City of Los Angeles a bureau to be designated as the Bureau of
Municipal Nursing. Said bureau shall be conducted by a commis-
sion of five persons not more than three of whom shall be doctors
or nurses. Said Commissioners shall be appointed by the Health
Commissioner for such term as may be designated by him, but in
no event to exceed four years from the date of appointment, and
all members of such commission shall serve without compensation.
Said Commission shall organise by electing one of its own members
President and may elect such other officers as it may deem neces-
sary. Said Commission shall hold regular meetings at least once
in every two weeks and three members shall constitute a quorum.
Section 2. Said Commission shall, under the direction and su-
pervision of the Health Commissioner take charge of school nursing,
instructive visiting nursing, contagious nursing, emergency nursing,
and nurses for investigation and inspection. Said Commission shall
from time to time recommend to the Health Commissioner such
action with reference to the proper methods to pursue in the carry-
ing out of municipal nursing as in its judgment may be deemed nec-


of opinion. Miss Ella Phillips Crandall describes the
gro\\1:h of this tendency so well that I quote her words:
^' The present highly specialised service of public health
nurses is a logical, if not an inevitable, result of the
gradual growth of public consciousness and conscience re-
garding better standards of living in general and of health
in particular. The tuberculosis nurse came as part of the
world wide campaign against tuberculosis, the school and
infant welfare nurse in response to the demand for a fair
start in life for infants and children, the medical social
worker as an indispensable factor in the practice of pre-
ventive medicine, and the industrial nurse as a part of the
employer's effort to keep his most valuable asset, the
workers, in the best possible trim. As each need was
recognised money was appropriated to meet it, and the
donors prescribed interest, and the workers' obligation not
to divert the funds from their specified purpose, naturally
produced specialisation and the present questionable status
of public health nursing service."

We hear much of the disadvantages of duplication of
work due to specialisation. The story of the family whose
five members were visited by five nurses because each pa-
tient required special advice or care is both picturesque
and telling, but the detail of duplication is not the most
important point in the question of specialisation. The
main issue is whether the people, individually and as a
whole, now and in the future, will be better served if
public health nurses specialise, as do the doctors, in cer-
tain lines of work. Both specialisation, and what, for
want of a better word, may be termed generalisation, have
their weak points, and in considering the subject we would
do well to separate the weaknesses that are inherent parts
of the method, and those which are due to poor administra-
tion. Neither the absurd lengths to which specialisation
has been carried, nor an unawakened interest in preventive
work on the part of some few general nurses, should be


allowed to condemn either theory. With all due regard for
dangers and limitations, each must be judged by its possi-
bilities under the best possible administration.

Opinion among nurses is fairly evenly divided on the
subject, some of the most thoughtful and experienced
nurses believing that public health nursing will always
be best carried on by means of specialised nurses, while
others, and perhaps an equal number, believe that special-
isation has been carried too far and that only through a re-
turn to the general nurse trained to care for all types of
cases can the best results be obtained. All are agreed that
in the large cities generalisation presents serious difficul-
ties and all are equally agreed that specialisation is finan-
cially impossible in small towns or rural districts which
must inevitably be served by a single nurse. A few of
those believing in a return to generalisation are inclined to
feel that specialisation will always be desirable for the
largest cities, and also in starting new forms of work.
They feel, however, that the very large cities are not
typical, and that agencies which are a part of purely edu-
cational institutions endowed for research form also excep-
tions, which will always have a part in any complete pro-
gram. Perhaps, the crux of the whole situation lies in the
difference of opinion as to the possibility of properly pre-
paring general nurses for all types of work. Advocates of
both methods are eagerly watching the experiments which
are being tried in various cities to generalise w^ork which
has previously been carried on under groups of special
nurses. The results of such experiments cannot be justly
estimated in any short period of time, and hasty conclu-
sions must be avoided. Nevertheless, each development
of these experimental efforts is instructive and enlighten-
ing. The establishment in half a dozen cities of so-called
Health Centres through which it is hoped to co-ordinate
all the health activities of a district, both medical and
social, is another experiment likely to prove illuminating.



The health centres eaimot yet be said to have passed an ex-
perimental stage for they have nowhere been established in
sufficient numbers to meet the needs of any city, nor do
they necessarily mean a generalisation of nursing work,
though the tendency is undoubtedly away from specialisa-
tion. A series of well-administered health centres w^ould
seem ideal laboratories for the trying out of many health
experiments, not least among them the best method of
bringing public health nursing to both sick and well.

Many things affect the question of specialisation in its
local aspects. Xursing traditions, civic and political con-
ditions, the personnel of staff, the attitude of the doctors,
the sources of financial support, etc., etc. Each situation
must, therefore, be studied in the light of its own local con-
ditions, but a brief consideration of the two points of view
may be helpful. The following are the arguments gener-
ally advanced by those who believe that generalisation of
public health nursing is desirable:

First. Erom an economic point of view, that an un-
necessary amount of money is spent both for transporta-
tion and for time when more than one nurse covers the
same territory, and that the duplication of overhead
expenses induces a temptation to economy of supervi-

Second. That the entrance of several different nurses
into a household tends to weaken the influence of each, as
the slightest discrepancy in method or advice is noted and
dw^elt upon, until the work of all is lost through confusion
of mind.

Third. That the constant presence in the small dis-
trict of one nurse so familiarises her to the people that
they learn to call upon her readily for advice in health
as w^ell as in sickness.

Fourth. That for the average nurse variety of w^ork
acts as a helpful stimulus, and that the monotonous round
of similar duties performed day after day cannot fail to


react badly upon her^ and in turn upon her work. This
is particularly true of tuberculosis nursing.

Fifth. Because as each individual phase of disease
is more and more coming to be recognised as a part of the
whole public health problem, requiring treatment as such,
specialisation should be avoided as tending to delay, or
prevent, such general recognition.

Sixth. That the excellent work now being done by
single nurses who work alone in small towns or rural com-
munities proves that all branches of public health nursing
can be successfully dealt with by one nurse.

To those who believe that the greatest progress is only
to be made through specialisation the foregoing argu-
ments are unconvincing, for it is felt that the same reasons
which have led to specialisation in other kinds of work,
lead, and ought to lead, to it in the field of public health

If it is true that the doctor who spends his time in study-
ing one form of disease becomes more expert in that dis-
ease than the general practitioner, and makes a greater
contribution to the accumulated knowledge of the subject
by carrying such knowledge farther than would be the
case if no specialists existed, why should the same not be
true of the nurse who works shoulder to shoulder with
him, giving her aid not merely in the intelligent care and
instruction of the patient, but by adding her quota to the
existing knowledge of the nursing side of the question.
That sacrifice must be made for this great gain is ad^
mitted, but that it is of such a nature as to make advisable
the retrograde step of a return to the " general practi-
tioner " alone, in nursing, is denied.

The first argument concerning the unnecessary, and
therefore unjustifiable, expense involved in carrying on
special lines of nursing by means of separate groups of
nurses, can only be met by a frank admission that such
expenditure can be justified only by a corresponding gain


in efficiency. The waste of the duplication of overhead
charges is not, however, necessarily a part of specialised
work, for its most ardent supporter would urge the group-
ing together of the various branches under one central or-
ganisation, thus avoiding this difficulty.

There is also a divergence of opinion in regard to the
important financial item of time, even among those op-
posed to specialisation. Miss Mary Beard, in an article
entitled '' Generalisation in Public Health ^N^ursing," ^
in which she earnestly pleads for generalisation on other
grounds, says: '' It would take more time and money to
adjust this situation (the single nurse in a small district)
because, with a small area to cover and a variety of duties
to perform, the work cannot be done as quickly as when
the same routine is pursued every day.''

The second point, as to the advantage to the patients of
a single nurse, the influence of whose advice is not weak-
ened by that of other nurses, is open to question ; for occa-
sionally in the multitude of counsel there is wisdom, and
one personality is sometimes able to succeed where another
has failed, presupposing, of course, a co-operation which
will prevent opposing advice.

To the third argument, that the presence of a single
nurse in a district so familiarises her to the people that
they readily call upon her at all times, we could but agTee
were the single nurse always ideal, and removed from the
human necessities of vacations, and sick leave, or the still
more disastrous possibility of marriage or removal.
Since, however, the ideal nurse is hard to find, and even
when found is by no means pennanent, does not greater
strength lie in the reliance by the patients and the people
of the district on what is represented by the uniform, than
in a faith which is pinned to a single personality ?

The fourth point, regarding the monotony of work for
the nurse who specialises, is of importance, but though the

1 The Public Health Nurse Quarterly, October, 1913.


majority of nurses might prefer the small district with the
greater variety of activity, others are glad to eliminate all
but a single type of service. Where, too, the special
branches are controlled by one organisation, a nurse may
be placed in different positions, thus varying her v^^ork be-
fore any touch of monotony reacts unfavourably upon her.

The danger expressed in the fifth argument, namely,
that specialisation tends to foster a microscopic examina-
tion of a single aspect of a family situation, thus obscuring
the problem as a whole, presents perhaps the strongest
objection to specialised work. It is a danger common
to all forms of specialisation, and can be avoided only
by a broad-minded grasp of public health nursing as a
whole, and a spirit of co-operation which will work for all-
round accomplishment. In it, however, lies a real
menace, and one which should not be lightly passed over.

The sixth assertion, that the excellent work done by
nurses working alone in small towns or rural communities
proves the ability of one woman to deal with the various
aspects of such work, may well be granted. But on what
foundation does her work rest ? Is not a part at least
of her success due to the fact that special nurses, in per-
haps far distant cities, have carried the technique of the
special branches farther than she would ever have been
able to do, and that it is on that advanced knowledge that
she is acting?

One practical detail of daily work has not been touched
upon : вАФ the danger that lies in the temptation to the
nurse who carries all types of cases to hurry on to the
patient acutely ill and needing bedside care, away from
the mother or tuberculous patient who is anxious merely
to '^ talk it out," a process that is so valuable to the patient
and that requires so much time from the nurse.

Setting aside the questions of practical detail, the great-
est drawbacks to specialisation w^ould seem to lie in the
danger that a broad grasp of health problems may be


missed by those doing the work, that those ministered to
may suffer from the effect of an unnecessary invasion of
their homes by a number of nurses whose combined in-
struction is less advantageous to them than that of a
single individual, and that those supporting the work may
be called upon for unnecessary funds, because of waste in
the expenditure of money for overhead expense, trans-
portation and nurses' time.

These are objections not to be lightly met by those who
urge a wise specialisation. An open-minded readiness to
admit a mistaken position, with an equal readiness to re-
trace steps taken on a wrong path, should mark those genu-
inely interested in the welfare of the public health nurs-
ing movement.

The writer, with all modesty, because she so highly re-
spects the judgment of those who differ from her, feels
that these serious objections to specialisation are not in-
superable. She feels that to reach the highest possibilities
in special lines of nursing there must be women giving
their entire time to these lines, and by so doing becoming
experts in them, able to lead others, able to contribute to
the literature which is so greatly needed, able, in short, to
do for the nursing profession what the specialist in medi-
cine is so successfully doing for the medical profession.



All good private or institutional nurses do not make
good public liealih nurses. A certain educational spirit
and a degree of executive ability, not perhaps needed to
the same extent in private nursing, are indispensable,
while resourcefulness and initiative, less necessary in the
ordered routine of a hospital ward, must be developed to a
high degree if success is to be achieved in public health

As a woman stands on the threshold of her nursing
career, with the decision before her as to which way she
shall turn her steps, she would do well to take time for
careful thought. It is sometimes a difficult matter to
extricate the round peg from the square hole, and valuable
time may be lost in the operation.

There are three things every nurse has a right to seek
in making such a decision. First, that the work she
chooses should be worth doing; second, that it should be
done under conditions which will destroy neither her
health nor happiness; third, that she should receive for it
a suitable financial remuneration.

In addition, she is quite justified in considering the

Online LibraryMary Sewall GardnerPublic health nursing → online text (page 6 of 29)