Part 16

The Bureau has been furnishing all personnel and equipment for the work in these hospitals, and this work should be established in the hospitals where there are 50 or more War Risk patients, and continued in the smaller hospitals where it is now established until the number available for this work is reduced to 20. In all contract hospitals where contracts are to be made in the future suitable supplies should be required of the hospital for this work as a part of the minimum standard for hospital requirements.

_PUBLIC HEALTH HOSPITALS_

Formerly the Public Health Service furnished all personnel and equipment utilized in Physiotherapy. The personnel utilized in Occupational Therapy was also furnished by the Public Health Service but the workers engaged in Pre-Vocational Training were furnished by the Federal Board.

In view of the consolidation of all three agencies for the care of the World War Veterans in the U. S. Veterans’ Bureau, the following relation is recommended between the Public Health Service and the U. S. Veterans’ Bureau. Physiotherapy Aides, and Reconstruction Aides used in Occupational Therapy, will be furnished by the Public Health Service and will be paid by them from appropriations made from time to time by this Bureau. The workers and teachers utilized in Pre-Vocational Training in Public Health Hospitals will be furnished and paid by the U. S. Veterans’ Bureau. The Aides will work directly under the medical officers in direct contact with the patient under the general supervision of the Medical Officer in Charge of the hospital. The teachers and workers in Pre-Vocational Training will operate directly under the Educational Director of the hospital, who in turn will be directly responsible to the Commanding Officer or Medical Officer in Charge of the Hospital.

_SUPPLIES_

Supplies and equipment for the work in Physiotherapy and Occupational Therapy and Pre-Vocational Training will be furnished by the Public Health Service or upon request of the Public Health Service by the U. S. Veterans’ Bureau.

_SUITABLE SPACE FOR WORK_

It is necessary, in order to carry on the work in Occupational Therapy and pre-vocational training to have well lighted space, properly ventilated and heated, suitable situated, and approximately, ten per cent of the bed space in a hospital. This, however, does not have to be in a ward, but may be provided in a separate building.

3. The general outline of the policy is that to serve the men in Occupational Therapy and pro-vocational training it will require one teacher for every 20 men at work, or for every 40 men in a hospital, exclusive of the administrative force, as it is estimated that only 50 per cent will be available for this work. Experience has taught us that, where there are 50 beds there will be 20 or more men available for this work, and that in such small groups trade work should not be undertaken, but in hospitals of 200 beds or more the work should be organized on the following lines—Occupational Therapy for ward work and pre-vocational training, to include academic, commercial, agricultural and trade work, as the survey of the hospital indicates and as the Medical Officer in charge may approve.

4. In organizing the work in new hospitals a survey of the needs and facilities shall be made to the Medical Division for approval before the work is established. When the hospital population has been so reduced in any unit that it is deemed impracticable by the Medical Division to continue this work, it may be closed at their direction.

5. It will be necessary to have specially qualified and experienced individuals in Central Office to be detailed to the Inspection Section from the Reconstruction Section to make inspections of the work in the hospitals, and approval for travel authorization and expenses incurred by this personnel is requested.

Robt. U. Patterson, Assistant Director, Medical Division.

Approved: _C. R. Forbes_ Director.

EXHIBIT B

U.S. VETERANS’ BUREAU January 18, 1922.

_GENERAL ORDER NO. 68_

Subject: ORGANIZATION AND ADMINISTRATION OF THE SECTION OF PHYSICAL RECONSTRUCTION, MEDICAL DIVISION, U.S. VETERANS’ BUREAU.

The following General Order is hereby promulgated, effective this date, for observance by all officials and employees of the U.S. Veterans’ Bureau.

1. The Section of Physical Reconstruction is under the Medical Division, and includes Occupational Therapy, Pre-Vocational Training, and Physiotherapy in hospitals and dispensaries, and Follow-Up Nursing outside of hospitals.

2. The internal management of hospitals of the Army, Navy, Public Health, National Soldiers’ Homes, St. Elizabeth’s Hospital, and Contract Hospitals falls under the jurisdiction of the several services mentioned, or in private and State institutions under the superintendent.

3. Occupational Therapy, Pre-Vocational Training, and Physiotherapy are a part of the hospital care and treatment, and fall under the management of the Medical Officer in charge of each institution, and do not come under the jurisdiction of the District manager or the District Medical Officer.

4. Institutions formerly known as Training Centers have been divided into two groups:

(a) All centers called Vocational Schools are under the Rehabilitation Division.

(b) All centers in hospitals will be called Reconstruction Centers and are under the Medical Division.

_ARMY_

In all Army Hospitals serving the U.S. Veterans’ Bureau beneficiaries reconstruction work will be established, and personnel, equipment, and expendable materials for Occupational Therapy, Pre-Vocational Training, and Physiotherapy will be furnished through the Surgeon General of the Army and paid for by the U.S. Veterans’ Bureau on a pro rata basis for such service to its beneficiaries.

_NAVY_

In all Naval Hospitals serving U.S. Veterans’ Bureau Beneficiaries Physical Reconstruction will be established and the personnel, equipment, and supplies for Occupational Therapy, Pre-Vocational Training, and Physiotherapy will be furnished by the U.S. Veterans’ Bureau for its beneficiaries in such hospitals.

_PUBLIC HEALTH SERVICE HOSPITALS_

The Occupational Aides and Physiotherapy Aides in Public Health Service Hospitals will be furnished by that service. The teachers in Pre-Vocational Training will be furnished by the Veterans’ Bureau. The Physiotherapy Aides will be directly under the Medical Officer in Charge of Physiotherapy, or, if no such officer is assigned, under the ward surgeons. The Occupational Aides will work directly under the Reconstruction Officer, if there is one assigned; if not, under the ward surgeons. Teachers and workers in Pre-Vocational Training will be directly under the Educational Director. The entire personnel of the hospital will be under the direction of the Medical Officer in Charge.

Supplies and equipment for Occupational Therapy and Physiotherapy will be furnished by the Public Health Service. Supplies and equipment for Pre-Vocational Training will be furnished direct by the Veterans’ Bureau.

_NATIONAL SOLDIERS’ HOMES_

In all National Soldiers’ Homes Reconstruction service will be established, and personnel, equipment, and supplies for Occupational Therapy, Pre-Vocational Training, and Physiotherapy will be furnished by the U.S. Veterans’ Bureau. The Aides in Physiotherapy are to work under the direction of the Medical Officer (Physiotherapist) assigned, or, if there is not such an officer, directly under the ward surgeons. The Occupational Aides and teachers in Pre-Vocational Training will be under the direction of the Educational Director. The personnel detailed to the Homes are under the direction of the Medical Officer in Charge.

_ST. ELIZABETH’S HOSPITAL_

Physical Reconstruction has been established as a part of the work in St. Elizabeth’s Hospital. The personnel, equipment, and supplies for Occupational Therapy, Pre-Vocational Training, and Physiotherapy will be furnished by the U. S. Veterans’ Bureau. The Physiotherapy Aides will be under the direct supervision of the Medical Officer assigned to the Physiotherapy Section, or, if no such officer is assigned, under the Medical Officers in charge of the patients being treated. The Occupational Aides and teachers in Pre-Vocational Training will be directly under the Educational Director. All personnel will be under the general direction of the Medical Officer in Charge.

_CONTRACT HOSPITALS_

In all Contract Hospitals, where the number of beneficiaries justifies, the Reconstruction Service will be established. All Personnel and equipment will be furnished by the U. S. Veterans’ Bureau. The Occupational Aides and teachers in Pre-Vocational Training will be directly under the Educational director. Physiotherapy Aides will be directly under the ward surgeons. The personnel assigned will be under the general direction of the Medical Officer in Charge.

_PROPERTY ACCOUNTABILITY_

The Educational Director in a center at a hospital will designate an employee under his jurisdiction as a Property Custodian, which Property Custodian will make the same semi-annual reports to Central Office as are required of District Property Custodians by General Order #52.

The accounting for physiotherapy supplies and equipment will be in accordance with General Order No. 52.

_SUPPLIES_

Supplies and equipment for Physical Reconstruction in hospitals other than Army and Public Health Service will be requisitioned from Central Office. Requisitions must be prepared in accordance with Field Order No. 43.

_SECURING PERSONNEL_

The personnel in the Reconstruction service is obtained through Central Office from Civil Service register. When the Educational Director at a hospital desires additional personnel he will make request through the commanding officer of the hospital to Central Office direct, stating the qualifications of individual required. Central Office will then make the most advantageous assignment possible and order the individual to report for duty at the designated station. In securing personnel for dispensaries and for follow-up nursing, the request will come from the officer in charge through the District Medical Officer and District Manager to Central Office, stating the qualifications of individual required. The Reconstruction Section will secure the name or names of individuals and request the District Medical Service Section to secure the appointment of the same through Personnel Division, and notify the District Office of the date the same shall go on their payroll and the amount of salary they shall receive. All personnel in the Reconstruction service, except the Occupational Aides and Physiotherapy Aides in Public Health Hospitals and Army Hospitals, will be on Central Office payroll. This will include teachers and occupational aides.

_TRANSFERS_

Transfers of personnel in hospitals will be made by Central Office upon the recommendation of the Commanding Officer and the Educational Director. Transfers of personnel on the District Office payroll in dispensaries and the follow-up nurses may be made within the District by the District Manager. If it is an interdistrict transfer, the same must be made by Central Office. All surplus personnel, either in hospitals, National Soldiers’ Homes, or in District Office, or in Sub-District Office, should be reported promptly to Central Office.

_COMMUNICATIONS_

All communications from Central Office to personnel in a hospital will be routed through the Medical Officer in Charge of hospital. All communications from personnel in a hospital will be sent through the Commanding Officer to proper destination. All communications to personnel in Reconstruction Section outside of hospitals will be sent through the District Manager to its destination. All communications from personnel outside of hospitals within a District shall be sent through the District Manager to its destination.

_SUPERVISION OF OCCUPATIONAL THERAPY AND PRE-VOCATIONAL TRAINING_

There shall be a sufficient number of supervisors of Occupational Therapy and Pre-Vocational Training employed and placed on Central Office payroll to properly supervise the work in all districts. Their duties shall be to supervise the work under the direction of Central Office, to keep Central Office fully advised as to the condition of the work and the needs of each reconstruction center they visit, and to recommend any changes in personnel, giving reasons for recommendations.

_PHYSIOTHERAPY_

There shall be a medical officer skilled in Physiotherapy designated as Chief of Physiotherapy for each district. He may be a part-time or a full-time man, as the necessity requires. His duty shall be to supervise and direct the installation of the equipment in the District and Sub-District Offices, and, upon request from Central Office, to visit and report upon the work in any hospital in his district. His line of communication will be through the District Medical Officer and the District Manager to Central Office; and Central Office’s line of communication will be to the District Manager—Attention, Chief of Physiotherapy.

_FOLLOW-UP NURSING_

Field Order No. 18 covers the entire matter of Follow-Up Nursing.

EXHIBIT C

File No.

U.S. VETERANS’ BUREAU October 19, 1921.

_FIELD ORDER NO. 18_

Subject: STATUS AND DUTIES OF NURSES WORKING IN THE PHYSICAL RECONSTRUCTION SECTION OF THE MEDICAL DIVISION, U. S. VETERANS’ BUREAU.

The following Field Order is hereby promulgated, effective this date, for observance by all officers and employees in the District Offices of the United States Veterans’ Bureau:

1. Appointment of Nurses.

All appointments will be made by the U. S. Veterans’ Bureau on the recommendation of the District Medical Officer with the approval of the District Manager under the regulations of the U. S. Civil Service Commission. Preference will be given to nurses who have had at least three years’ general nursing experience outside of an institution, particularly to those who have had experience in tuberculosis, neuropsychiatric and Public Health Welfare nursing.

2. Administration.

Nurses on duty in the districts will be carried on the District pay-rolls and will be responsible to the Chief Nurse of the District, who in turn will be responsible to the District Medical Officer under the District Manager. The work of all nurses in the various districts not on duty in hospitals will be directly supervised by the District Medical Officer who will be responsible through the District manager to the Medical Division; U. S. Veterans’ Bureau (Physical Reconstruction Section), to whom communications on matters in connection with their work should be addressed.

3. Chief Nurse.

In each district a Chief Nurse will be appointed by the Central Office of the U. S. Veterans’ Bureau through the Assistant Director in Charge of Medical Division upon the recommendation of the District Medical Officer and with the approval of the District Manager. The duties of the Chief Nurses in the districts will be to superintend the activities of the nurses in their respective districts, to visit the local offices when directed by the District Medical Officer, to inspect the work of the nurses, to co-ordinate the work of the nurses in the districts, sub-districts, and local offices and to check up the nurses’ reports. It will also be the duty of each Chief Nurse, through the District Medical Officer and the District Manager, to keep the Superintendent of Nurses in the Physical Reconstruction Section of the Medical Division, U. S. Veterans’ Bureau, informed of the quality of the work performed by the individual nurses under her direction. Reports of especially good work, or unsatisfactory work, should be sent in detail to the Superintendent of Nurses through the District Medical Officer and the District Manager. The Chief Nurse in each district will instruct nurses under her charge as to the proper form for conducting correspondence and of the channels through which the same will be sent.

4. Duties of Nurses.

_General Duties._

(a) To assist Medical Officers of the Districts, whenever there is one at their station, in the care of beneficiaries who may require medical supervision and care.

(b) To keep contact with claimants and refer possible claimants to the proper authorities for the adjustment of their needs.

(c) To conduct medical follow-up work under the immediate direction of the local or sub-district authority where there is no medical officer on duty.

(d) At station where there is a social service worker to refer proper cases to them. If no co-operating social service agency is available the nurses will perform such social service duties as time will permit in addition to their regular duties.

(e) Whenever the address of a beneficiary is found to be incorrect, nurses will report correct addresses to the nearest Bureau Office immediately.

(f) Nurses, when visiting claimants, will give their residence address for emergency calls to each claimant under their care and supervision.

_Special Duties._

These may be grouped under three heads:

1. For Tuberculosis Claimants:

(a) Ascertain state of health from time to time. Record pulse, temperature, etc., to detect evidence of tuberculous toxemia. Note gain or loss of weight; presence of cough. Amount and character of sputum, etc.

(b) Ascertain their state of morale and that of their families.

(c) Give simple instructions regarding health and appropriate advice from time to time.

(d) Furnish literature of appropriate character when same is available.

(e) Emphasize the value of hospital care for those who become sick from other causes or whose pulmonary condition becomes active.

(f) Report promptly to the nearest medical officer beneficiaries whose condition seems to indicate that hospitalization is necessary.

2. For Neuro-Psychiatric Claimants:

(a) Health instruction and definite advice with regard to home conditions.

(b) Advice and supervision to prevent intemperance, excessive use of tobacco, drugs, etc.

(c) Advice regarding habits, whether married or single.

(d) Note general behavior and mental state, such as stream of talk, mental activity, characteristics of same, such as incoherence, inattention, distractibility, etc.

(e) Note mood of beneficiaries, such as preoccupations, hallucinations, illusions, etc.

(f) Endeavor to obtain insight as to how much the patient realizes the nature of his present condition or of previous illnesses.

(g) Interpret claimant’s condition to his family and instruct them in the necessity for tolerance of claimant’s peculiarities.

3. For Claimants with General Disabilities.

(a) Make visits to beneficiaries pending hospitalisation, or after being discharged from hospital, while in training, particularly those said to be absent from training on account of illness, reporting results of investigations to the local medical officer. If an emergency arises the claimant should be sent immediately to a designated physician, if too ill to report to a physician, a physician in the employ of the Bureau will be notified of the name and address of the patient and requested call. A report on each case will be made to the nearest local office, together with recommendations and a statement of any action that has been taken. If Claimant’s absence from training was not due to illness that fact will be communicated to the local Bureau authority.

(b) Report on every case assigned to her and render subsequent reports on such cases as may be required from time to time; to make supplemental reports from time to time as may be necessary. Such reports will be made on Medical E, or other designated form, and will have for their object the discovery of present results of service disabilities, intercurrent ailments, or physical conditions which are preventing the physical rehabilitation of the man. The attention of the District or local medical officer will be called to any seemingly improper conditions, and recommendations will be made looking to their correction. Subsequent reports will show whether or not these conditions have been remedied. For the purpose of reducing the number of visits that are required the claimant will be induced to call at the office if practicable.

(c) When calling at the home of a patient the nurse will notice the sanitary conditions of the home, particular attention being given to plumbing, adequacy of rooms, air space per capita, light, heat, bathing facilities, number of flights of stairs necessary to reach quarters, etc. Information as to how long claimant has lived there and if he has made frequent changes of residence. Recommendations will be made for improvement of conditions which appear to be prejudicial to the health of the men and his _family_ and an earnest endeavor will be made to have them corrected. In case the _family_ of a beneficiary needs medical treatment or other attention the social worker or in her absence the Red Cross or other Co-operating agency will be notified.

(d) Reports on Medical G, or other designated form, will be made on cases that break down in training, indicating when possible the cause of the interruption of training, whether the same is actually due to a reactivation of the original disability, to an intercurrent condition, or to extrinsic causes connected with training, work, or living conditions. Medical Form G, or other designated form, will be forwarded through proper channels to the District Medical Officer or his nearest representative.

(e) To visit at stated intervals all cases in localities in which there are not county nurses, and to endeavor to obtain contact occasionally with county nurses, where such are on duty, with a view of keeping them informed of conditions for the best interest of the ex-service man.

(f) Field notes on all of the above duties will be conveniently kept on Assignment Memorandum Form 701, or other form that may be designated hereafter.

5. It is not the function of the nurses to supervise Vocational Training. She is not to intimate to the beneficiary any doubt as to whether he is assigned to the proper course, or whether institutional or job training is best suited to his needs, but any suggestions she can give to the Training Officer in regard to the man’s attitude towards his training, will be helpful in his rehabilitation. Nurses will not call men away from their work for the purpose of interviewing them, unless by special arrangement, suggested by the Training Officer.

6. In territory where a nurse and a Social Service worker are both on duty, the nurse is not to attempt to investigate social conditions or make recommendations for rectifying them, if unsatisfactory conditions are found. _Per contra_ the Social Service worker is not to assume the work of the nurse in investigating conditions affecting the health of the beneficiaries. Emergency cases will arise where it will be obviously advantageous to the interests of the beneficiaries for whether a nurse or a Social Service worker to take immediate action on a matter not strictly within her province, but when this has to be done the other should be at once notified of the circumstances.

7. Nurses will not be expected to assist in special nursing except in training centers, or in temporary emergencies when it is impossible to hospitalize claimants, or where there is no person available to give instruction in home nursing.

C. R. FORBES, Director, U. S. Veterans’ Bureau.

EXHIBIT D

NURSES’ CONSOLIDATED REPORT for NOVEMBER, 1921.

_SUMMARY_