TABLE 14.--Death rate from nephritis per 100,000 population, by color, in the District of Columbia and selected cities, 1920-34 1 Includes all places of 10,000 or more population in the death-registration States. TABLE 15.-Infant mortality per 1,000 live births, by color, in the District of Columbia and selected cities, 1920-34 Includes all places of 10,000 or more population in the death-registration States. 'Data not available before 1927. TABLE 16.—Death rates from all puerperal causes per 1,000 live births, by color, in the District of Columbia and selected cities, 1920–34 1 Includes all places of 10,000 or more population in the death-registration States. 2 Data not available by color. Data not available before 1927. TABLE 17.-Death rates from puerperal septicemia per 1,000 live births, by color, in the District of Columbia and selected cities, 1920–34 1 Includes all places of 10,000 or more population in the death-registration States. Data not available by color. Data not available before 1927. PUBLIC HEALTH NURSING By MARY J. DUNN, Regional Public Health Nursing Consultant, U. S. Public Health Service The subject of public-health nursing will be considered under the following headings: I. Estimate of public-health nursing needs, and recommendations for improvement of the public-health nursing service in the District of Columbia. II. Summary of major recommendations of the 1929 survey, with special comments. III. Agencies providing public-health nursing service-brief description of organization, personnel, and program of each. A. Instructive Visiting Nurse Society. B. Child welfare society. C. Bureau of public health nursing, District of Columbia I. ESTIMATE OF PUBLIC-HEALTH NURSING NEEDS AND RECOMMENDATIONS FOR IMPROVEMENT OF THE PUBLIC-HEALTH NURSING SERVICE IN THE DISTRICT OF COLUMBIA In light of the facts gleaned from the survey, it would appear that the outstanding public-health nursing needs of the District of Columbia include the following: 1. Expansion of the following existing services: (a) Tuberculosis. (b) Demonstration and instruction in isolation of acute communicable diseases. (c) School nursing facilities. (d) Postpartum nursing care. (See Maternal, infant, and preschool hygiene report.) (e) Nursing care of pneumonia patients. (f) Out-patient department nursing service. 2. Provision for nursing assistance in services not now included in the nursing program. (a) Home delivery service. (See Maternal, infant, and preschool hygiene report.) 3. Ways and means of preventing duplication of effort and gaps of service. (a) Interdepartmental. (b) When two or more agencies are involved. RECOMMENDATIONS 1. Increase the nursing personnel of the bureau of public health nursing of the health department in accordance with the standard recommended for desirable performance. (See table 1.) The estimation of nursing needs may be determined— (a) On the basis of population. The ratio of one public health nurse to every 2,000 population for a completely generalized nursing service; or (b) On the basis of actual health conditions and needs with respect to the number of births, acute communicable disease cases, venereal disease cases, deaths from tuberculosis, and the number of infants, preschool and school children in the population. On the basis of population the public health-nursing needs for the District of Columbia would require about 300 public-health nurses. On the basis of health needs there would be required at least 250 public-health nurses. The total number of public-health nurses in the District of Columbia at the present time is 162. It is recognized that provision for adequate public-health nursing service in any community is primarily the responsibility of the health department. In a community in which there exists more than one agency providing public health nursing service, policies are established, usually, to determine the allocation of types of service to be performed by the respective agencies, and the order of precedence by which patients or families will be served by the various agencies. However, with a full realization of the significance of the foregoing statement, it is still encumbent upon the health department to provide, directly or indirectly, sufficient public-health nursing service to meet the needs of the community. This responsibility may be met in two ways: (a) Directly, by the expansion of the service of the health department through the appointment of additional personnel, sufficient to render the complete public-health nursing service indicated; or (b) Indirectly, by purchasing from the private visiting-nurse agency those services which fall in the category of bedside nursing care for those who are unable to purchase such care for themselves. 2. Provide nursing assistance for the following services through the purchase of services from the Instructive Visiting Nurse Society: Home delivery service (See Maternal, infant, and preschool hygiene report). Home nursing care of pneumonia patients. It should be the responsibility of the health department to provide adequate home nursing care for pneumonia patients who for various reasons cannot be hospitalized and cannot purchase adequate nursing care for themselves. This might well be one of the services to purchase from the Instructive Visiting Nurse Society. It is of interest to note that during the calendar year 1936 the Instructive Visiting Nurse Society cared for about 550 pneumonia patients, with an average of eight visits to each patient, or an annual total of 4,400 nursing visits to pneumonia patients. The average annual deaths from pneumonia in the District of Columbia approximate 600. The estimated cases per death are 4, or an estimated total of 2,400 cases of pneumonia annually. The number of pneumonia patients registered annually with the Instructive Visiting Nurse Society (approximately 550) furnishes an index to the number brought to the attention of this agency; undoubtedly, there are as many more who need nursing care in their homes, who do not come to the attention of the I. V. N. S. and who are unable to pay for the service. Therefore, the nursing needs for the care of pneumonia patients might be estimated in terms of the full time of four nurses, although the care of pneumonia patients would be distributed among all of the generalized field nurses rendering a bedside nursing service. 3. Strengthen and improve the out-patient department service of the hospitals by appointing as supervisor of the nursing service a well qualified public health nurse. The trend of present-day thinking in the field of hospital administration, as well as of public health, is that the hospital should serve the community from the preventive, as well as from the curative aspect. The out-patient departments of our hospitals with their ambulatory clientele are in a particularly strategic position to realize the attainment of this goal. To the degree that the personnel of the out-patient department is in accord with this viewpoint, and to the degree that emphasis is given to the preventive functions and the positive elements of health, to that extent will there be realized a reduction in the disabilities and cost of disease and an improvement in the health condition of the community. It is realized that the average out-patient department serves predominantly the lower economic groups. Also, it should be borne in mind that in most cities the out-patient departments serve between 25 and 30 percent of the total population, and that the average individual patient makes between three and four visits per year. Thus, it is evident that the educational opportunities in the out-patient clinics are manifold. Therefore, it is recommended that at least the supervisor of the nursing service in each out-patient clinic be a wellqualified public health nurse. 4. To the end that duplication of efforts, conflicts, and lapses in service might be prevented within the health department itself and when other agencies are concerned, it would seem desirable to: (a) See that the clinic registrar secures accurate and complete data as to name, address, telephone number, working hours, etc., as a means of reducing the number of "not home" and "not found" visits. (According to the 1937 report 13.5 percent of the total visits were nonproductive because the individual was not home or could not be located.) (b) See, also, that helpful information secured by the field nurse in home visiting be transmitted promptly and fully to the clinic personnel. This would eliminate much needless questioning, and general ineffectiveness in the clinic. (c) Make greater use of the social service exchange both from the viewpoint of registering and of clearing patients and families. (d) Make further study of the functions of the social service exchange, the central admitting bureau, and the health department permit bureau, with the view to eliminating duplication and confusion in the referral of patients and possibly amalgamating these facilities. (e) Encourage joint conferences of staff nurses of the agencies serving the same area in order to evolve jointly plans for the families which may be served by more than one agency. 5. Select a limited area of the District of Columbia in which the existing public health nursing agencies might experiment in the working out of a completely generalized nursing service, including bedside nursing service, under the direction of a joint board or advisory committee. Hiscock, Ira: Community Health Organization, p. 214. |