Nursing is no longer a vocation, but a profession. Since the time of Florence Nightingale, it has formed a definite part of hospital organization. Formerly nurses were trained under an apprenticeship system. They were exploited by hospitals, but this did not seem to occur to them, because of their high ideal of consecration to service. In this early period of the history of nursing, emphasis was placed upon the practical aspect of the work.
With the development of the school of nursing, theory began to be recognized as of equal importance with practice. Attention began to be focused on better education for nurses, which meant better care for patients. To protect the nurse from further exploitation, and assure her that she was receiving the proper education in her school of nursing to fit her for the profession, nurses (through their various organizations) formed a Committee on the Grading of Nursing Schools.' The work of the committee covered eight years. Its final report is given in "Nursing Schools Today and Tomorrow." As a result of this work, schools were placed on a sound basis, for no hospital today is allowed to operate a nursing school which is not listed on the registry of the American Medical Association. In addition, the committee considered the better education of nurses as important. It advised specialized training for nurses, and endeavored to supply sufficient nursing service.
The work of this committee has been an outstanding achievement in the field of nursing and in hospital service. A different kind of woman now enters the profession—one who does not consider nursing as a good vocation alone, or look upon it from the viewpoint of the idealism of its service; but one who also views it in its broader perspective, thinking of its ,educative and social service. The nurse is an educator and a social worker whether she is ,conscious of it or not. Dr. Haven Emerson goes so far as to say :
"I have often felt that there is among the nursing group the largest potential power for the correction of social ills that exists within the country, because nobody else knows what is the horror, the fear, that 'hangs over people from unemployment, as the nurse does. Nobody sees what it means to be politically "hounded the way the nurse does of the home which is subject to political catastrophe. The nurse knows well what it means for a family breadwinner to suffer a reduction of wages. The nurse is the eyes and conscience of the community in seeing and judging those matters which adversely affect the health and life, the survival of babies and children and parents in the home."
In the hospital the nurse contacts all departments. An interrelationship exists between her and the medical staff, the adjunct departments, and the administration. Often she is the only confidante of the patient. She must keep a correct record of her observations, of symptoms, or of any physical or mental changes of the patient. She must co-operate with the administration in reporting the seriously ill. No hospital today is considered efficient which does not have a well-qualified, well-disciplined nursing staff. Good nursing service is one of its greatest assets.
Hospital Functions.—Institutions originate because of fundamental human needs. They survive because they satisfy these needs. They are based upon a nuclei of interests, tradition, and custom. They are among the more stable forms of control.'
The hospital in its social structure compares favorably with the nature of other human institutions. It, too, has been built up around a nuclei of sentiment, tradition, custom, and interests. By the nature of its complex organization, its particular type of function, its personnel, the hospital has become one of the most firmly established social institutions.
Its chief interest is the patient. It primary function is the care of the sick and injured for whom it must provide the type of care and service which will result in the most effective cure or improvement of the patient. All other functions are subordinate to it ; but have become a part of the responsibility of the hospital, because they contribute indirectly to the care of the patient.
Nursing as a social institution is as old as the human race, but nursing as a profession is a nineteenth-century innovation. Through their national and State organizations, nurses have raised the status of nursing from a state of exploitation to a profession. Today, the nurse receives part of her formal education in other institutions of learning, and part of her theoretical and practical training in the hospital.
The Patient.—The patient, who is the most important person in the hospital, is no passive observer of all that it attempted for his restoration to health and participation in normal society.
Illness is a reality through which new values may be developed and attitudes changed. The patient finds his normal course of life rudely interrupted. He has been accustomed to employment ; now he must submit to enforced idleness. In his active life, he has had no time for contemplation ; now he has more time than he desires. He has been accustomed to making his own decisions; now they are made for him. He is advised regarding practically every detail of his bodily affairs, which formerly he considered as his own private business.
In his illness, his understanding may be enhanced by contact with others, or his prejudices may be deepened, his fears strengthened. He may be overcome by discouragement, or he may defeat it. He may learn new values by making modifications and finding satisfactions and new strength through direction and growth within himself. He must learn to accept his limitations and improve his capacities. He must get adjusted to his diagnosis and treatment and his hospitalization. Through his contact with the hospital personnel, he is taught daily adaptation and adjustment to his condition and to his environment.
Every member of the hospital personnel contributes directly or indirectly to the education of the patient. While he is in the hospital, he can be taught certain health concepts and the prevention of a possible recurrence of his present illness. For example, if his illness has been due to a dietary problem, he may be instructed in certain facts of nutrition. If he has a special diet, he may be guided in his adaptation of his diet to a normal routine of life. He may be taught the benefits of creative recreation, and the principles of healthful living.
To help the patient more effectively, in his education and rehabilitation, medicosocial service has been introduced into hospitals and is becoming an accepted part of clinical medicine. Medicosocial service is not a twentieth-century innovation, but dates from the monastic almoner of the Middle Ages. The present hospital social service, as a new profession, is but thirty years old. Dr. Richard Cabot is credited with being the first to integrate medical-social service into the plan for satisfactory medical care. It is now a recognized fact that effective medical care must contribute to the total personality. Between disease and poverty there exists an intimate relationship, as also between a satisfactory income and adequate medical care, and between social maladjustment and social integration. What hospital social service is has been adequately defined by Lewis: "Hospital social service is an attempt to interpret and adjust the terms of one to the other, the patient's medical liabilities to his social assets."4 Its objective is to "save human life for some purpose, safeguard human relationships precious to the person."
The purpose of medical-social service is defined by MacEachern:
"The purpose of medical-social work in the hospital is to obtain and apply such understanding of the patient as will enable the institution, the physicians, and other agencies to comprehend and treat his illness more effectively."
Disease has always been recognized as a potent social factor. It disrupts family life, frustrates cherished ambitions, demands physical and mental adjustments, focuses the mind on body functions which have, heretofore, not entered into one's consciousness. There are emotional instability and character manifestations which in health were more or less under control. The patient's religious resources are often severely drained, his confidences enhanced or severely shaken. Pain, fear, worry, the feeling of insecurity, inadequacy, and helplessness not infrequently form the mental environment in which the patient lives.
The services of the medical-social worker are varied, but the major activities are:
I. "Inquiry into the social situation of the hospital patients, and the reporting of the findings to the responsible physician.
2. "Determining, in collaboration with the physician, the factors in the social situation pertinent to the patient's health, and stating these as medical-social problems or diagnosis.
3. "Setting up, in collaboration with the physician, a possible goal or best estate for the patient to aim for, given the medical problems and the social situation of the patient, and distinguishing the role the social worker is to play in the plan for helping the patient achieve his goal.
4. "Executing the social worker's part in the plan for helping the patient achieve his best estate."
The medical-social worker, by finding out the patient's general health problems, his economic, domestic, and industrial status, establishes an understanding of him, and in turn helps him to understand the things he needs to know for his personal welfare, sees that he is properly cared for, and, if possible, restored to health. If he needs help during his period of convalescence or chronic care, she assists him, by making contacts with other social agencies. She helps him to become adjusted to his environment, especially where there is a home environment or emotional disturbances that affect his health.
An understanding of the patient as he usually lives, thinks, feels, and acts, as well as knowledge of his usual place of abode or physical environment, is essential in order to give medical care that will embrace the whole health problem of the individual. This information the medical-social worker is able to furnish.
Medical-social service has not yet become an established department of the hospital in the same sense as the clinical laboratory or other departments. Emerson believes that it should become an integral part of hospital organization, however. Such a department is to be provided for in the hospital budget, in order that a study may be made of the patient's social and economic conditions, as well as his physical and psychic states. Thus the treatment may be more accurate and effective. The editors of Modern Hospital, in a beautiful tribute to medical-social service, state :
"The social service is the conscience of the hospital. Without it, rules and regulations would be far more rigid and the policies of the hospital far more inflexible. . . .
"Social service, in its most typical form, warms the heart of the scientist and prevents him from becoming reconciled to suffering. If the patient does not get the full benefit of its ministrations, the fault, as a rule, lies elsewhere. When the physician or surgeon has done his best and has not succeeded, it is the social worker who is left holding the bag."
(To be continued in May)
BIBLIOGRAPHY
1 Johns and Pfefferkorn, "An Activity Analysis of Nursing," Report of the Committee on the Grading of Nursing Schools, New York City, Committee on the Grading of Nursing Schools, 1934.
2 Haven Emerson, M. D., Trained Nurse and Hospital Review, February, 1941, p. 101. (Reprint from Public Health Nursing, August, I930.)
3 Joyce 0. Hertzler, "Social Institutions," p. 25, New York, McGraw-Hill Book Company, 1929.
4 Ora Mabelle Lewis, "Hospital Social Service for People of Moderate Means," "Transactions, American Hospital Association," 31 :245, Chicago, American Hospital Association, 1929.
5 Malcolm T. MacEachern, M. D., "Hospital Organization and Management," p. 539, Chicago, Physician's Record Company, 1935.
6 "Functions of Hospital Social Service," American Association of Hospital Social Workers, Monograph I, June, 1930, pp. 62, 63.
7 "A Tribute to Social Service," The Modern Hospital, 54:50, March, 1940.