Florence Nightingale, Part 3

This is part three of my three part post of a paper I wrote in 1994 about Florence Nightingale. You can read part one here and part two here. I had a good time revisiting this paper from almost thirty years ago.

Amy Mittelman ©2020, Professional Nursing I,                                                           Fall 1994

FLORENCE NIGHTINGALE

Lauren Smith used the Nightingale concept of management to frame her discussion of clinical nurse specialist (CNS) managed care for the chronically ill child.  In myelomeningocele clinics in Ohio, clinical nurse specialists provide case management.  Smith argues that this case management has provided early identification and intervention, continuity of care, increased parental advocacy skills, improved social and development skills for the children as well as professional growth and interdisciplinary collegiality for the nurses. She feels this work has carried out Nightingale’s directive of knowing that “what you do when you are there shall be done when you are not there.”[1]

Smith’s article was part of two in a recent issue of Clinical Nurse Specialist presented under the heading “Florence Nightingale: A CNS Role Model.”[2] The other article, “CNS Roles in Implementation of a Differentiated Case Management Model,” did not mention Nightingale.[3]

In doing research for this paper, I found many references to Nightingale, particularly in Japanese nursing literature. I disagree with the opinion expressed a few weeks ago that modern nursing views Nightingale as outdated. She remains a starting point for many nurse scholars and many nurses are eager to link their work with hers.  This may explain why that article appeared under the rubric “Florence Nightingale: A CNS Role Model” even though it did not mention Nightingale. Other examples of this are an article in Nurse Educator that is a letter by a nursing student to Nightingale and a response written by a Nightingale scholar, an article by Elise Gropper that claims Nightingale as “Nursing’s First Environmental Theorist,” and the work by Giger, Davidhizar and Miller that links Roy and Nightingale.[4]

Smith is an example of clinical use of an aspect of Nightingale’s theory. However, there are not that many explicit clinical examples because many of her themes – particularly asepsis – are an integral and unquestioned part of nursing today.  A Nightingale nurse caring for an ill hospitalized patient would not focus on the medical aspects of the patient’s condition. Nightingale did not consider that part of the nurse’s domain. As a Nightingale nurse you would assess the environment of the patient, paying particular attention to sanitary issues. You would draw your diagnoses from those functional health patterns that are environmentally oriented including Activity-Exercise, Sleep-Rest, Role-Relationship and Nutritional. Decreased Cardiac Output would not be an appropriate Nightingale diagnosis, but Impaired Physical Mobility or Impaired Skin Integrity would be. Your goals for the patient would focus on preventing illness from environmental conditions. Thus, your interventions would involve repositioning if the patient was bedridden, providing a restful, clean atmosphere and keeping the patient’s skin clean and dry to prevent skin breakdown.

Florence Nightingale had a tremendous impact on the history and development of nursing as a profession. I found it interesting and informative to read her work.  Many of her practical suggestions are still applicable today. Perhaps her claim that “observation, ingenuity and perseverance … really constitute the nurse” says it all.[5]

[1] Smith, Lauren D. 1994. Continuity of care through nursing: Case management of the chronically ill child. Clinical Nurse Specialist 8 (2), p. 68.

[2] Sparacino, Patricia S.A. 1994. Florence Nightingale: A CNS role model. Clinical Nurse Specialist 8 (2): 64.

[3] Brubakken, Karen, Wendy R. Janssen, and Diane L. Ruppel. 1994. CNS roles in implementation of a differentiated case management model. Clinical Nurse Specialist 8 (2): 69-73.

[4] Decker, Bernita, and Joanne K. Farley. 1991. What would Nightingale say? Nurse Educator 16 (May/June): 12-13; Gropper, Elise I. 1990. Florence Nightingale: Nursing’s first environmental theorist. Nursing Forum 25: 30-33; Giger, Joyce N., Ruth Davidhizar, and Scott Wilson Miller. 1990. Nightingale and Roy: A comparison of nursing models. Today’s OR Nurse (April): 25-30.

[5] Nightingale, Florence. 1860. Notes on nursing. New York: D. Appleton and Company, p. 65.

 

 

 

Florence Nightingale, Part 2

This is part two of my three part post of a paper I wrote in 1994 while in nursing school. You can read part one here. Nightingale’s advice on sanitary practices, especially frequent hand washing, seems very relevant.

Amy Mittelman ©2020,                                                                                   Professional Nursing I, Fall 1994

FLORENCE NIGHTINGALE

In Nightingale’s view the environment was also nature centered and physically based; it was the nurse’s responsibility to manipulate it to provide sanitary conditions. Her emphasis was one of prevention. “True nursing ignores infection, except to prevent it.  Cleanliness and fresh air from open windows, with unremitting attentions to the patient, are the only defense a true nurse either asks or needs”[1] Giger, Davidhizar and Miller have found Nightingale’s focus on the environment to be similar to Sister Callista Roy’s adaptation nursing theory.[2]

In 1860 the germ theory of disease was not a part of scientific discourse.  As it became prevalent, Nightingale refused to believe it.[3] Because Nightingale believed that disease was a reparative process, external forces such as dirt, odors, and poor diet had to cause it. She would not accept that a person could get sick in sanitary conditions.  Nightingale did not believe that medicine was a “curative process . . . nature alone cures.”[4] Health was a state of nature; illness was a response to a disruption in that state.

Although Nightingale rejected the germ theory of disease which is a cornerstone of modern medicine and nursing, many of her opinions on sanitary practices are still appropriate. She emphasized frequent hand washing, the value of fresh air, the evils of dirty carpets, the importance of modulating the stimulus a patient receives, and the importance of maintaining a patient’s spirits. These all remain critical aspects of caring for a patient and effecting recovery.

Nightingale believed that the same guidelines of sanitation applied to the healthy as well as the sick. The person was a subject of nature and had the responsibility to observe nature’s law in such a manner (sanitary) as to avoid infection and illness.  Again, the emphasis was prevention.[5]

To Nightingale, the nurse’s role in the reparative process was “to put the patient in the best condition for nature to act upon him” She felt that nursing should “signify the proper use of fresh air, light, warmth, cleanliness, quiet and the proper administration of diet – all at the least expense of vital power to the patient.”[6]

Nightingale advocated a patient centered nursing. She stressed the importance of “sound observation” for “the sake of saving life and increasing health and comfort.” Although Nightingale emphasized the high level of attention that the nurse must undertake, she also pointed out the importance of delegating responsibility as a way of knowing that “what you do when you are there, shall be done when you are not there.”[7]

 

[1] Nightingale, Florence. 1860. Notes on nursing. New York: D. Appleton and Company, p. 34.

[2] Giger, Joyce N., Ruth Davidhizar, and Scott Wilson Miller. 1990. Nightingale and Roy: A comparison of nursing models. Today’s OR Nurse (April): 25-30.

[3] Vicinus, Martha, and Bea Nergaard. 1990. Ever yours, Florence Nightingale. Cambridge, Massachusetts: Harvard University Press.

[4] Nightingale, Notes, p.133.

[5] Ibid.

[6] Nightingale, Notes, p. 133, 8.

[7] Nightingale, Notes, p. 125, 35

Constance Green

Last week I finished the chapter of my book about faculty wives that I have been working on for over a year. The chapter, “Aristocracy” is about the gendered and hierarchical nature of academia. I wound up using one family, the Angells, as the framework for the chapter. One woman, Constance Green became the focus. Constance McLaughlin Green was an urban and technology historian who, in 1963, won a Pulitzer Prize for her book on Washington, D.C. She died in 1975.

On Dec. 5, 1975, I was living in my parent’s apartment following my college graduation. My boyfriend who I had lived with my senior year was now in England on a scholarship. A scholarship I had helped him get while not applying for anything myself.

I was depressed and in pain from sciatica that had developed after I got out of the backseat of a two-door car. As I read the New York Times that day, I came across Constance Green’s obituary. “That’s it”, I thought. “I’ll go to graduate school and be like her.” She had gotten her Ph.D. from Yale; a school I wanted to go to because I loved the architecture.

Forty-five years later I have written a mini biography of Constance Green. The more I found out about her, the more her life story resonated with me. Of course, I have not; and will never win a Pulitzer Prize. I am the descendant of immigrants not college presidents. What strikes a chord with me is her determination to pursue scholarship and writing history.

Stuck in Holyoke, she was determined to go to graduate school. Harvard’s dismissal of her as a woman with children who belonged at home did not deter her. Although I did not have children when I got my Ph.D. I was pregnant with my first child when I defended my thesis.

A few years earlier, I applied for a job at Wesleyan. The man interviewing me asked if I was planning on having any distractions. This was code for asking if I was pregnant. I doubt if a man would ever receive a question about possible parenthood. As for Western Massachusetts, as a native New Yorker who had never lived anywhere else, the first year I lived in Northampton I constantly felt that I was living deep into the country, far away from civilization.

Constance Green did not receive her PhD until she was forty and had three children at home. She never held a traditional full-time academic position. She had a prestigious career because she persisted in pursuing something that mattered deeply to her.

When I decided to switch careers, I did not know how or if I would keep doing historical scholarship. I had 2 small children. It turned out that, like Constance, I had to persist. The first year I worked as a nurse, I spent a week’s vacation going to Amherst College to research The Ladies of Amherst. Twenty-one years after I defended my dissertation, I published Brewing Battles.

Both Constance Green and I came from generations that feminism impacted but neither of us were able to fully realize the benefits. My book is bringing back into history woman like us.

 

 

 

 

Notable Nurses Part Two

This is the second part of the list from Regis College. The information about Margaret Sanger is somewhat problematic. As the birth control movement progressed it moved further and further away from its’ radical roots and  often embraced eugenics and population control rhetoric.

Susie King Taylor (1848-1912): First African-American Union Army Nurse in the American Civil War

Lillian D. Wald (1867-1940): Public Health Advocate

  • Shortly after beginning classes at the Women’s Medical College in New York, during a trip to coordinate classes for immigrants in New York’s Lower East Side, Wald was so shocked by the poor state of health of those living in tenement houses there that she felt she needed to do something. She left school and founded the Nurses’ Settlement at Henry Street to help those most in need of medical care.
  • At the Nurses’ Settlement, Wald and a small number of other nurses pioneered the field of public health nursing. The group charged for medical care on a sliding scale. They hoped that by adjusting how much they charged based on the means of their clients, they could make health care affordable to everyone.
  • Wald’s bold decision to leave the medical establishment and prioritize the general health of the community was a success. Her efforts at improving the health of her community, as well as educating future medical practitioners on the need for this service, contributed to the founding of the National Federation of Settlements. Much like Wald’s Nurses’ Settlement, this organization aimed to provide desperately needed medical aid and public services to the communities that needed them the most. The field of public health nursing would eventually become its own profession.
  • Wald became the first chairperson of the National Organization for Public Health Nursing, which worked to develop this new field.

Margaret Sanger (1879-1966): Founder of Planned Parenthood

Mabel Keaton Staupers (1890-1989): Advocate for Racial Equality in Nursing

Notable Nurses Part One

A reader sent me something her sister sent her. Both are considering  careers in health care. It is from the Regis College website and is a list of prominent nurses from the nineteenth century on.

I will confess that I hadn’t heard of few of them, however, it seems  like good information to pass on so I am posting it here. The list is long so I have divided it in two. The links are from the Regis site. As always comments as well as additional names are welcome.

Dorothea Dix (1802-87): Mental Health Advocate

  • Dix discovered her passion for teaching when she opened her first school at 15 years old, but it wasn’t until she was 39 that she discovered her second passion. While teaching classes in a women’s prison, Dix found that mentally ill and developmentally disabled women were imprisoned there under inhumane conditions. Horrified by what she had seen, Dix decided she had to do something to end the practice of confining these groups of people in prisons rather than caring for them.
  • This new calling inspired Dix to travel across the United States and Europe visiting prisons to advocate for better treatment of those within. She eventually brought her arguments to Congress and convinced legislators to support the opening of the Government Hospital for the Insane. This facility still exists and is now known as St. Elizabeth’s Hospital.
  • When the Civil War broke out in 1861, Dix traveled to Washington, D.C., where she became a nurse attached to the War Department. She was soon made superintendent of Army nurses. She stayed in that position until the end of the war.

Clara Barton (1821-1912): Founder of the American Red Cross

  • During the Civil War, Barton saw the desperate need for medical supplies and services on the front lines of battlefields. She took it upon herself to travel to battlefield after battlefield offering care to both armies. This earned her the moniker “The Angel of the Battlefield.”
  • Once the war was over, Barton traveled to Europe, where she again provided nursing services to wounded soldiers, this time in a war between France and Prussia. There, she was inspired by the newly organized Red Cross. Upon her return to America, Barton founded the American Red Cross.
  • Once the American Red Cross was established, Barton turned to expanding the organization’s duties from battlefield aid to disaster relief. Eventually, the organization would begin providing aid internationally. Today, the American Red Cross provides health and disaster relief services around the world.

Linda Richards (1841-1930): First Formally Trained Female Nurse

  • Richards became the first American nurse to complete a formal nursing program in the United States when she graduated from the nurse training program at the New England Hospital for Women and Children in 1873.
  • Her most lasting impact on the history of medicine came when she saw how the lack of medical records in most hospitals caused patients to suffer. There were no reliable records of patients’ previous conditions, chronic illnesses, or treatments that had already been tried. Having these medical records on hand would help doctors determine the best way to help their patients. Richards eventually developed an organized system of note-taking and record-keeping to ensure that this was no longer a problem.
  • Richards never stopped working to improve her profession and became a leading educator in her field. She started nursing schools in the United States and abroad. Richards even traveled to Kyoto to help establish Japan’s first nurse training program in 1885.

Mary Eliza Mahoney (1845-1926): First African-American Registered Nurse

  • Mahoney worked as a private-duty nurse at the New England Hospital for Women and Children for years before she was finally admitted to the hospital’s nursing program in 1878.
  • She was the first African-American woman to complete formal training and become a registered nurse in the United States.
  • When the Nurses Associated Alumnae of the United States and Canada, now known as the American Nurses Association, expressed prejudice against people of color within their organization, Mahoney left the association. She then became a founding member of the National Association of Colored Graduate Nurses to advocate for the dignity and equality of minorities in the nursing profession.
  • In 1936, the National Association of Colored Graduate Nurses began awarding the Mary Mahoney Award to a person or group making strides to integrate the nursing profession. This award continues to be granted to those who carry on Mahoney’s legacy of promoting equality for minorities in the nursing professions.

 

Addiction Treatment

Yesterday I listened to Preet Bharara’s podcast, Stay Tuned with Preet. The topic was the opioid crisis. The guests were Susan Salomone, a parent advocate and Dr. Abigail Herron, a psychiatrist who works with addicts.

Part of the discussion was on treatment and what is available to help addicts. Salomone believes that currently there are not enough days for treatments. When I worked in an inpatient detox unit, the addicts were only there for 5 days and then placed in outpatient care.

Dr. Herron discussed the medical treatments that are available. There are three.

Methadone is the oldest treatment available. It is dispensed in licensed clinics and the clients usually attend every day. After a certain number of clean random drug screens, some people can get take-home privileges and reduce the number of days they have to attend the clinic.

Because methadone is an opioid and can be abused, methadone as treatment for addiction is controversial. If a person wants to stop taking methadone they will suffer withdrawal symptoms just like heroin. However, when I worked at a methadone clinic I saw many people whose lives were saved by being on methadone

Naltrexone is an opioid inhibitor. It can be used for alcohol addiction as well as opioid addiction. It reduces cravings. Unlike methadone which stays in the body for a long time, naltrexone only works if you take it. There are no withdrawal symptoms. It is available as a pill or inject-able. The injection, which is very expensive, is supposed to last for thirty days but often wears off before that period is up.

50 mg is the usual dosage for the oral medication. Low dose naltrexone, approximately 4.5 mg, is used for a variety of illness including ALS, urinary issues and Crohn’s disease.

Buprenorphine is an opioid but only partially attaches to opioid receptors. With this drug there is supposedly no euphoria. Physicians are required to take a special course before prescribing buprenorphine. Because it is an opioid, stopping the drug does cause withdrawal symptoms.

All three of these treatments have some negative aspects. It is clear that a drug alone will not prevent a relapse. I think you would have to also be under the care of a therapist and attend support groups regularly. Many people believe that addiction causes brain changes that are difficult to undo. Addiction is a disease of relapse. Just ask anyone who has tried to stop smoking.

Understanding Addiction

Last Thursday I attended a seminar on “Understanding addiction.” The Institute for Natural Resources sponsored the one day seminar which was a way for nurses and other medical professionals to collect continuing education credits.

Much of the material was familiar to me and I don’t think I learned that much that was new. One interesting thing is that alcohol, tobacco, and even caffeine are now seen as drugs with psychoactive properties similar to the illegal drugs such as opioids or cocaine. In fact the legal drugs cause more societal problems than the illegal drugs. The seminar handout states that alcohol and tobacco costs the United States over $400 billion a year  due to crime, lost work productivity, and healthcare. Costs associated with Illegal drugs are about $181 billion a year.

There is an opioid crisis but the speaker did not spend that much time on it. He made the point that at different times different drugs are in fashion. Unfortunately heroin seems to be in vogue right now. It is clear that the War on Drugs has failed and we need to invest much more money on treatment. We also need to find a balance between maintaining pain medicines for people with chronic pain while reducing the more casual prescribing of opioids.

 

 

On the Road to Health: VB6

I have decided to write about something that is a little more personal than what I have usually posted on this blog. It is not about beer (except indirectly), women (except that it is about me and I am a woman), nursing, (except that health maintenance is a big part of nursing)or history (except that patterns of food consumption is a very complicated historical subject). Anyway …

Today my husband and I are starting to follow Mark Bittman’s VB6. The short version of this is that he became a part time vegan several years ago and lost thirty pounds and got healthier. He wrote a book about it and then a cookbook.

We decided to do this because I would like to eat healthier. Last year, because of various medical issues, I went from March to June not eating soy or cow diary. That was quite an eye opener as I discovered that soy is in everything we eat and use.

Of course, like most people, I would like to lose weight but I don’t think his weight loss was typical. I totaled up the calories for one day of his 28 day diet plan and it was 1800 calories. If I ate 1800 calories a day I would gain weight. I think his weight loss came from giving up alcohol which I bet he drank a lot of. I am not saying he was or is an alcoholic but I am pretty sure that people in the food business drink a lot.

Bittman’s plan is for you to eat vegan for breakfast and lunches and then healthy dinners that can have animal products. He also wants you to try as much as possible to eat “real” food; if commercially prepared it should have five ingredients or less. His final stipulation is no alcohol or a lot less. He says; “More than anything else in the VB6 diet, alcohol is a judgment call: definitely off limits during the day, and up to you at night. But if you’re seriously trying to lose weight, very limited drinking – or none at all – is something to consider.”

Bittman’s admittedly arbitrary division of vegan before 6 p.m. really doesn’t work for us. The lunches seem like they take a long time to cook and if you are not at home for lunch how do you do that? We decided to try to be vegan for dinner because that is the meal it seems we can handle. Breakfast is pretty much vegan without trying unless you have bacon and eggs which I usually don’t. For now we are leaving lunch as the meal that can be non-vegan but we will see how that goes.

I am writing this before we have had our first dinner. I will let you know how it turns out.

Black Friday

This Facebook post by Robert Reich  https://www.facebook.com/RBReich about all the stores that will be open on Thanksgiving made me reflect on how I have spent Thanksgiving and the day after over the years.

Before I  was a nurse, I briefly had a job as a bell-ringer for the Salvation Army.  People didn’t call the day after Thanksgiving “Black Friday” then but it was a huge  shopping day and  the kickoff for the holiday season.  Now the holiday season starts before Halloween which is one sign that our economy is not doing great.  It felt funny to me, as a Jew, to be ringing the bell for this Christian organization but people didn’t realize that I was being paid and thanked me for my service.

Once I became a nurse I often worked on Thanksgiving. If I was working a 7-3 shift when I got home we would go out to eat. One year my husband and one of my sons cooked dinner which was a real treat. When I worked 7-7 my family met me at the hospital and ate in the cafeteria with me.

This year my Thanksgiving  and Hanukkah will be spent with family and not shopping. Thanksgiving is a nice holiday because it is non-denominational and a time to relax. In our 24/7 society we need days of rest and no commercial activity.

 

Occupy Sandy

On Monday I was in New York City and I volunteered with Occupy Sandy. Because I am a nurse I was sent to Far Rockaway to help in a clinic that was being started at St. Gertrude’s Church. I had responded to a tweet and was told to show up at St. Jacobi’s in Sunset Park. I was then driven with two street medics, from Boston, to Far Rockaway.

Because there was not electricity in many parts of the island, there were a lot of cops directing traffic. Many roads were not passable; either because they had become dirt or because various crews were working on them. Part of the time we drove along the beach. There is no longer any boardwalk; instead there are huge piles of wood and sticks as well as equally huge piles of dirt and sand.

Along streets there were cars facing every direction, often covered with mud. I saw one car with its front end facing completing down and stuck.  As we drove along, on empty lots and parking lots there were ad hoc clothing and food drives. This was neighbors helping neighbors.

Although there were a lot of cops, I did not see any FEMA presence. I saw one Red Cross worker walking in the street. St. Gertrude’s was affected by Sandy. Parts of the building in which the relief effort is taking place were flooded and there were people working on restoring the damage. On Monday the building had not yet had full power restored.

The clinic had been started the day before and it was not really set up. Four nurses from NYU Hospital spent several hours sorting through the medical supplies that had been donated and  organized and set up a basic clinic. Volunteers at St. Gertrude’s have been going out and canvassing the neighborhood to see what inhabitants need, particularly concerning medical issues.

At about three o’clock I went with two street medics to check up on several residents in a high-rise apartment building.  We started to climb the stairs and at almost every landing someone had placed a chair. We saw a couple of elderly women siting and gathering their breath We climbed seventeen lights of stairs but the person on that floor did not answer. On the sixteenth floor a Russian speaking women said she was fine and did not need any help. On the fifteenth floor a man who appeared somewhat confused needed some psych meds refilled. I was able to get his Prozac but because Xanax is a controlled substance I couldn’t really do anything. After that we climbed back down. While we were in the lobby the repairman finally got elevators to work. Oh well it was good exercise.

The relief effort at St. Gertrude’s is part of Occupy Sandy which is a part of Occupy Wall Street. The experience I had volunteering on Monday to me reveals both good and bad aspects of the occupy movement. The relief effort at both St. Jacobi and St. Gertrude’s was very disorganized. I had received two emails from two different people. Neither was at St. Jacobi when I got there.

The street medic who took me to Far Rockaway was a volunteer from Boston. The person at St. Jacobi supposedly placing medical personnel did not really know anything about St. Gertrude’s and the clinic. I got a ride out there but was on my own to find a ride back.  This was something that was not made clear to me before I left St. Jacobi.

I think it is terrific that Occupy Wall Street has organized to try to provide relief to people who have been devastated by Sandy.  I do think the effort could use some more consistency and organization.  Both FEMA and Occupy Sandy have gotten good press. The situation on the ground is more nuanced.