Part 11

Most important of all we have striven in every way to secure a qualified medical personnel, a matter of no small difficulty. The demand for competent medical men is greater than the supply. In the operation of such a large hospital system it is by no means easy to secure men skilled in special lines of endeavor. We have, therefore, felt the need many times of establishing some system of educating our medical staffs in various matters and, while funds have not permitted the extension of this system, we have availed ourselves of educational methods as far as possible. Schools of various kinds have been held for short periods of time and men have not infrequently been transferred temporarily to situations where they might acquire a special knowledge. We have also encouraged staff conferences and attempted to supply working libraries and medical magazines to each of our hospitals—all with the idea of stimulating among our entire medical personnel the desire to increase their professional efficiency as much as possible.

3. Finally, we have not overlooked the necessity for research. Our funds have been too limited to do a great deal in this line, but we have felt keenly the responsibility which rested upon us to do all that was possible. Such activities have been carried on in a very small way with the exception of one or two hospitals which might be really called research hospitals, notably such a hospital as the one at Waukesha, Wisconsin, where every effort is devoted to the diagnosis and treatment of a definite class of Neuro-psychiatric disorders. This hospital has been so organized as to permit the very highest type of modern diagnosis and therapy.”

GEN. SAWYER: “This seems to me to be on opportunity to say a thing or to which have been in my mind that I wish to express now. First, this present administration has as one of its ambitions the best Public Health Service in the world. I want you to know that, in your engagements here, trying as they are, behind you is a determination to help to develop an ideal Public Health Service, and every man who is engaged in the service of the Public Health of the United States should feel that he is engaged in the greatest service that can be rendered to his country.

For myself, I have a great ambition that somewhere there should be established a post-graduate training department to which the members of the Public Health Service of the United states could come for post-graduate training. We want to be the highest type of doctors that are to be found anywhere, and so today we have in contemplation the establishment of a post-graduate training school in the city of Washington, to which you can come to provide yourselves and equip yourselves with all the new and better things that from time to time must develop.”

SURGEON DEDMAN: stated that he felt that Dr. Lavinder’s paper was too important to pass up without a comment or two; that one thing he was struck with was the personal contact to be made with the patients themselves. He said he believed this was a very important matter, as the services of a doctor are absolutely worthless until he has gained the patient’s confidence. He felt that the doctor should be looked upon just as the family physician at home. He stated further that when he first entered the work he made the following hospital rules: 1—Kindness, 2—Cheerfulness, and, 3—Duty. Said that the doctors should inject the feeling of friendship into the minds of the men as much as possible. He stated that there ought to be a system of uniform hospital regulations, that some hospital rules are not so drastic as those of other hospitals, and that he believed there should be a uniform regulation so that the disciplinary regulations would be the same in one hospital as in another.

ASST. SURGEON. L. L. WILLIAMS: stated that in reference to uniform disciplinary regulations the character of the patients, the location of the institutions and the construction of the premises are all factors that affect the privileges to be given the patients. Believed there could be no highly organized uniformity of regulations.

In regard to specialized attention, the hospital should be prepared to furnish any sort of special care possible. He stated further that he believed that the specialized patient in a general hospital is better off than if in a special hospital, but that if he had a son who had a special ailment he would much prefer him in a hospital which had upon its staff men in active practice of the kind he was going to need.

CAPT. LOWNDES: said there was always some patient who would go out and make trouble, that he had been investigated by the American Legion, by ladies’ committees and by religious societies, all of whom he invited to come to the hospital, as there was trouble if they were told not to come. He said he had met with two criticisms: one was that the nurses were particularly harsh, to which he replied that he generally had trouble getting the patients to go out as some of them generally fell in love with the nurses; the other that the patients would not pay any attention to the Commanding Officer when he made inspections.

GEN. CUMMING: “The next subject “Nursing” will be presented by the Superintendent of Army Nurses, Major Julia C. Stimson.”

MAJOR STIMSON: read the paper “Nursing”, as given herewith:

“The subject of nursing in relation to the care of the ex-service man is a very big one and can scarcely be handled adequately in the ten minutes allotted to it. There are, however, certain phases of it that can be mentioned.

The response of the nursing profession to the call of the country during the time of war is well known, and the character of the achievements of the 25,000 trained women who entered the government services at that time has been often recounted, but little has been told of the patriotic devotion to duty that has been exhibited by nurses since the Armistice. I have not come today to bring bouquets and laurel wreaths, but I do wish to call attention to the marvelous development of one branch of governmental nursing work under conditions that in many instances were harder to bear than most war conditions, and to ask for the service the recognition and cooperation it deserves. At the present time there are more nurses in the U.S. Public Health Service, (1796), than there are in the combined nursing departments of the Army, (774), and the Navy, (488). The figure given me for the present Public Health nursing staff is about 1800, an expansion from forty odd at the time the service was authorized to care for ex-service men, on March 3, 1919 by Act of Congress. To realize the full meaning of this expansion and the development of the organization required to manage the service, it is only necessary to recall the fact that in the spring of 1919 when the Public Health Service called for volunteers for its Nursing Service, the Army and the Navy were both discharging from their Nurse Corps great numbers of women. In one month alone in that year 2500 nurses were demobilized from the army. They were all tired, worn-out women. You all recall the state of mind of both the soldier and the officer during those months, when morale was at its lowest ebb, because of homesickness, fed-upness, and desire to get back to civil life. Nurses as well as men were full of complaints, and to be freed from governmental control was the thing that to all of them seemed the ultimate good. Moreover, many who came from overseas had been marking time for weeks, awaiting orders for the breaking up of their units, and embarkation, and upon their arrival home they found their communities, which they had left so short of nurses, were clamoring for their services.

Under such conditions was presented the need of the ex-service man. A new federal nursing department asked them to give up their personal desire for freedom, their longed-for plans, and to enter—what? and to do—what? It is hardly necessary to describe the kind of hospitals these nurses were asked to enter, nor the conditions under which they were to live. You would scarcely believe the details that I could tell you unless you, too, have heard the accounts of the able Superintendent of Nurses of the Public Health Service. You know, perhaps, what some of the old Marine hospitals are like, and some of you know some of the old Army hospitals taken over by the Public Health Service were like. You don’t know, I am sure, about the utterly unworthy and unsuitable quarters and messing arrangements for nurses which many staffs have had to endure, and still do endure in some instances. The fact that there are now 1800 nurses in the service bears witness to the clearness of her vision of the need on the part of the Superintendent of the Corps, and her valiant presentation of it, and to the assistance given her by the American Red Cross Nursing Service which has spread the call and facilitated recruiting.

The Nurse Corps of the Army and Navy were old, established departments, with traditions and customs behind them, with a status recognized by all in the service and honored by officers and men alike for their many years of efficient work.

The nurse in the U. S. Public Health Service had no such advantage, and to her and her associates and to the officials who have championed her cause against what have at times seemed almost unbearable difficulties too great praise cannot be given.

General Sawyer has asked me to present the difficulties that lie in the way of the kind of nursing service to the veteran that ought to be given, and to suggest if I can, a plan for meeting these difficulties.

The greatest problem of the nursing care of the ex-soldier is not in the Army and the Navy, because the proportion of the veterans patient to the regular Army and Navy patient in those services is so low that it presents no particular problem. It is, of course, in the U.S. Public Health hospitals that the problems exist most noticeably.

First we must consider the type of patient. We are told that neuro-psychiatric, contagious, and tuberculosis cases predominate. Right here is one difficulty as far as nurses are concerned. To contribute the highest type of service to people so afflicted requires that the living conditions, the mental and physical recreation and up-building of the nursing staff, be of the finest order. I think that this is conceded by all who consider the long hours during which the nurse is in close contact with the patient and who realize that no individual, barring none, has so large an opportunity for personal influence upon patients as the nurse.

Nurses who are employed for the care of the veteran should be of the highest grade. Not only should they meet all the professional and technical requirements, but they should be especially qualified in all phases of rehabilitation and reconstruction, both mental and physical. They should have an especial knowledge of the problem of the tuberculosis patient, not only as an individual sick man, but in his relation to society. They should be thoroughly cognizant of the magnitude and urgency of the problem of social diseases, and without an ability to help the neuro-psychiatric patient redirect his interests into the world of reality and to correlate himself and his environment, they are failing in their whole duty to their patient.

Under the present conditions it is probably not an easy matter to get such super-nurses in any great numbers, and even were it possible to secure them, it is not likely that they could be long retained. The turnover in the nursing service in hospitals caring for veterans is unduly large, the reports show. This has been due in some degree to physical breakdown, and also to dissatisfaction with conditions, including uncertainty as to their status and fears for its future. What, then, is to be done? The answer is not so hard to find. Locally, it is comfortable living quarters, reasonable hours, good food, the right sort of recreation, adequate pay, and opportunity for advancement and improvement. Nurses, like all other professional workers, are coming to recognize that in order to live up to their highest ideals and to give their best services to afflicted humanity, it is essential to make provision for continual growth, and that from time to time added inspiration and education are necessary. Courses of special study are advocated, therefore, for all nurses, especially for those caring for veterans or any other particularly difficult group of patients. Opportunity for post-graduate study is considered a necessity in the Army for both officers and members of the Nurse Corps, and it is even more important in the U.S. Public Health Service. In some hospitals of this service special courses have been conducted for nurses with marked success, but particular emphasis should be given to this phase of meeting the nursers’ problems. For before a nurse can help to reconstruct a distorted mental outlook and restore a normal attitude toward life, she, herself, must have an understanding and a sympathy and a power to help that can only come from steady inspiration, constant study, and serenity of mind.

Second in importance locally is the recognition on the part of the commanding officer of each hospital and each member of the hospital staff of the real place of nurses in the endeavor to return the patient to normal health and life, and emphasis upon an attitude of helpfulness and cooperation in all matters concerning them. Only those who have served in hospitals where the commanding officer was heart and soul in sympathy with the problems of the nursing staff and concerned with every detail that might work for its well-being, can know what a harmonious, helpful atmosphere can exist, and how the spirit of courteous recognition and mutual respect can permeate from the commanding officer to every member of the personnel. For is not the nursing group usually the largest group in every hospital, and will not the attitude of the nurses give the tone to the hospital? Commanding officers should remember that in their hands and their’s alone rests the regulation of this tone.

In all the presentation of the general subject of the care of the ex-service man, at this conference, little if any mention has been made of the part of the nurse. Right here in this very fact, perhaps, rests one of the largest snags that lie in the way of the best service to the veteran. Think for one moment of the situation if there were no nurses to work side by side with the medical man and to cooperate with him in securing for the patient that which he, with his special preparation, considers necessary for his healing. What results would be obtained? The time has passed when the need of professional nursing in the care of the sick is a debatable question. And yet nursing, as vital to the modern scientific restoration of the war veteran, has not been mentioned.

Here at headquarters is where the greatest progress toward the solution of the nursing problem can be made,—1st, in the recognition of the problem and its importance, and 2nd, in a sympathetic, concerned, business-like attempt to solve it by the method that is most sure to bring about success,—namely the conference method, the collecting of advice from experts on the subject, the formulation of their suggestions, and an endeavor on the part of all concerned to put these suggestions into practice.

You, in this new governmental organization, which has for its aim the highest type of service to veterans and their restoration to complete living, have a chance to develop a nursing department that should set the standard for all the departments of federal nursing as well as for civilian institutions.”

GEN. CUMMING: “Discussion will be offered by Mrs. Higbee”.

MRS. LENAH S. HIGBEE, Superintendent, N.N.C.: stated that the subject hardly needed discussion, that it would almost seem that she could not amplify it, but that was what she was going to attempt to do. She spoke on “Nursing”, as follows:

“Since the nurse viewpoint of the treatment of patients under the Veterans’ Bureau is considered sufficiently important to be discussed, it is a matter of regret that the chief nurses of the hospitals have not been summoned to this important conference. Of course, the nursing subject comes directly under the Commanding Officers of the hospitals but in presenting the more intimate views of the nurses, the opinions of the chief nurses would be more helpful than the opinions expressed through the medium of the superintendent whose knowledge of the situation is obtained from reports.

My knowledge of the situation we are discussing is obtained from reports. Letters have been sent to the various chief nurses requesting definite information on this subject and asking if any particular presentation could be made to this important body which would be helpful.

_NURSING._

At the Naval Hospitals which have had the greatest success in treating the Service beneficiaries, the Commanding Officers have put a frank presentation of the situation to the patients, pointing out the necessity for certain restrictions and discipline, and urging cooperation. This preliminary presentation by the Commanding Officers when followed by the kind yet firm supervision of the ward officers and also by the tactful, helpful attitude of the nurses, who in turn cooperate with the welfare and vocational workers, in time break down the attitude of opposition, resentment, and destructive criticism which many patients have when first hospitalized. The chief nurses have stated that the care of the patients means only “more patients.” There is no special problem in dealing with them and under the above conditions, they accept the necessary discipline and restriction which are fundamental if hospital treatment is to succeed.

It would seem, therefore, that the problem, as has already been pointed out, exists chiefly in the U. S. Public Health Hospitals where the greater number of patients from the Veterans’ Bureau are receiving care and treatment. A large percentage of these patients would correspond to our Navy ambulant cases and among the remainder (as has already been stated) the neuro-psychiatric and tuberculous patients predominate.

There is considerable discussion among doctors, at present, regarding the fundamental qualifications which the trained nurse should possess; and there have been charges of over-education and a tendency to commercialism which result in unrest and in losing sight of the basic principles of their profession. The charge of commercialism is so unworthy of the medical profession that I shall let it pass without comment but I do not consider it beside the present question to touch upon the statement of over-education. It may be conceded that a nurse, possessing a preliminary graded school education, who has been carefully taught for two or three years in an accredited hospital, is able to give nursing care, under medical supervision, to the sick bed patient. Her greater value to the physician and to the patient because of greater knowledge due to higher educational standards need not be discussed here. However, it should be conceded, also, that the influence of nurses on the patients of the Veterans’ Bureau is more constructive mentally and morally than is the influence of nurses who care for the acutely sick; which is, usually, particular personal care for a comparatively brief period. To care for convalescent and Veterans’ Bureau patients is to serve long hours of duty in which little change in the physical condition of the patients is noted; and yet so great is this responsibility, so important is the work from humanitarian and economic viewpoints that the nurses must ever be on guard against the insidious lack of interest which comes from routine care; and they must keep themselves so alert that their great opportunities for personal influence among these men shall not be neglected in any particular. With any degree of sickness, there is distorted judgment and predisposition to give undue stress to trifles. The educated nurse knows this and knows also that the semi helplessness of protracted convalescence and the resultant sense of dependency, are among the chief factors which must be considered in dealing with these special patients. She must influence the patients to be receptive to hospital restrictions; she must counteract the tendency to destructive criticism and disloyal statement; she must be sympathetic but not maudlin; she must recognize that they are ill but she must not encourage helplessness: she must suggest activity and encourage pride in endeavor and accomplishment. She must present the best viewpoint to the particular patient and this means an individual understanding of him and his needs. Only educated nurses (meaning that the aim of education is to develop the faculties of the mind and body) who have courage, refinement and dignity, who are loyal to their country without the stimulus of war, and who strive to maintain the high ideals of their profession can be definitely successful in co-operating with other agencies to restore these men to health. Reconstruction and Rehabilitation of the ex-Service men cannot be an affair of merely rearranging tangible elements, such as food, money and clothes: It is by example, by encouragement to make an effort to overcome helplessness, an explanation of the reasons for necessary treatment and restrictions, that the nurse will succeed in helping to replace quiescent dependence with the unsleeping desire and motive of service as active citizens. More and more it is recognized that we must look to education to destroy irrational suspicion and to restore to health and sanity.

The Public Health Nursing Service has been established a comparatively short time and yet under the Surgeons General of that Service and due in a great measure to the indefatigable efforts of the present superintendent and because of the high professional standard she has always maintained, more qualified nurses are attached to this Service at the present time than in the combined older services of the Army and Navy Nurse Corps. Having procured these nurses who, for the most part, it is believed, accept the additional responsibilities which the care of such patients involve, every effort that is made to retain them is worth while; since their value increases with length of service. From an economic viewpoint, if for no other reason, efforts should be made to give these nurses adequate payment for trained service; to provide living conditions which they require as educated and refined women; to recognize that rest and recreation are necessary if the physical standards and morale are to be maintained; to acknowledge their professional status and to give recognition to them as co-workers with the medical profession. With these requirements satisfactorily adjusted by those who have the power of formulating the necessary rules and regulations, the work of the nurses who care for the maimed bodies and sick minds of the patients of the Veterans’ Bureau will be productive of even greater beneficent results than have already been obtained;—for such nurses seek to maintain the fabric of the world; and in the result of their unselfish efforts is their prayer.”

MISS LUCY MINNIGERODE, Superintendent of Nurses, U.S.P.H.S., gave a further discussion of “Nursing”, as follows:

“Major Stimson has placed before you some of the most urgent problems and difficulties existing in the Nursery Service of Public Health Service hospitals dealing with the ex-service men.