Tuesday, October 18, 2011
I've been blogging for almost two years. 506 total posts, 507 including this one. Because I haven't been posting as much these past few months, some quick math will reveal that I was posting at a pace of more than once per day for well over a year. Social media experts, some of whom really are experts and many of whom are merely self-anointed Facebook and Twitter addicts who are trying to parlay their passion into a profession, say that frequent posting is important. Similar experts describe the endless economic possibilities and boundless business upside associated with maintaining a blog. Particularly if you're a CEO. They'll tell you it's something you just gots to do...
So I did it. Faithfully. For a long time.
Was it valuable? Well... yes and no. For me, it's been valuable. At the peak, I was getting close to a thousand unique visitors a day and several other industry blogs linked theirs to mine. In the I'll-scratch-your-back-if-you-scratch-mine world of social media, I always wondered if those other bloggers really liked what I had to say... or whether they were just in search of reciprocity. No matter, many flocked to my blog. And many commented. It was good. For me. At industry association meetings, colleagues walked up to me and said: "hey, I like your blog"... or even, on occasion, I'd get questions and feedback about something specific that I said. I never exactly became an internet sensation, but my ego felt sensational. A highlight came earlier this year when at a big conference for home care CEOs, a speaker, touting the benefits of social media, put up there in front of the ballroom my own blog front page. He spoke, gushed actually, about how great my blog was. My hits went through the roof for the next two weeks. I received emails from strangers telling me how cool I was. Nice.
But what's the business value? How does this translate into real value for my organization? That, I'm still not so sure about. It might be there, but I've just not been able to mine it. Yet.
That's why this isn't a farewell. It's a time out. I'm going to stop posting for a while and see if anybody misses me out there in cyberspace.
The world is changing and those social media experts, self-anointed and otherwise, might yet be right. If so, I'll be back.
In the meantime, if you're in search of the best home care, hospice or private care services on the planet, check out www.bostonvna.org.
If you're looking for me, I can be found at firstname.lastname@example.org.
Monday, August 8, 2011
If you've been following along, you know that the VNA of Boston story started far away from here (in Europe, in fact). Here's where it gets interesting... as we've now made our way to Boston. Here's Rebecca's post:
Today we arrive in Boston, about a quarter century after the founding of district nursing in England. In 1884 Abbie Crowell Howes, the unmarried daughter of a well-to-do Boston family, travelled to Liverpool to learn about Rathbone’s system of district nursing for the sick poor with hopes of establishing a similar program in Boston.
The period of reconstruction following the end of the Civil War in 1865 ushered in an era of rapid industrial, economic and population growth often referred to as the “Gilded Age”, a term coined by Mark Twain. During the 1870s and 1880s, the U.S. economy grew at the fastest rate in its history, and northern coastal cities were quickly transformed as new industries flourished and people flooded in to fill the need for workers. As in Liverpool of the mid-1800s, these new residents, in the over-crowded and poverty-stricken inner cities, often succumbed to sickness and disease leaving their families without income and threatening the social fabric of the community. At the same time, the professional and business classes became very wealthy, and many women pursued charitable activities to ease the suffering of the working classes and to promote improvements in education and health.
One such group in Boston was the Women’s Education Association (WEA). In 1871, Mrs. Charles Pierce and Mrs. B F Brooks sent out a circular proposing the establishment of an organization to support the expansion and quality of educational opportunities for women. At the first meeting, 75 women joined as charter members. Members would propose ideas for promoting the education of women, form committees with other ladies who had similar interests, and receive small grants from the Association to help jumpstart their project. The Association would remain involved for one or two years, with the expectation that the project would either take root in the community and become self-supporting or would fold. Several of the organizations started by members of the WEA include Radcliffe College, the MIT Women’s Laboratory, The Boston Training School for Nurses (the second oldest nursing school in the US based on the Nightingale model), The Boston Cooking School (where a scientific approach to food preparation was taught and where Fanny Farmer trained), the Marine Biological Laboratory at Wood’s Hole (a place where both men and women could conduct research and women were encouraged to be a part of the community of scientists – Rachel Carson formed many of her ideas at the MBL), and the Boston Children’s Museum.
Abbie Howes and her friend Phebe Adam were members of the WEA and upon Howes' return from Liverpool; she approached Adam to propose they request a grant from the WEA to start a program of district nursing in Boston. In her book, The Evolution of Public Health Nursing, Annie Brainard describes Howes as finding satisfaction and happiness in service to others. “As a social worker she had no interest in any personal rewards such as office or leadership for herself, but with rare persistence and tireless enthusiasm gave herself, at all times to the service of the poor and needy.” She describes Adam as “a lady of dominating personality” who “to some seemed stiff and forbidding, though to those who knew her better was a loved and revered leader. She had intellectual tastes and had taught school for some years. At the time of which we speak she was connected with the Shaw Day Nursery in Boston and, having already realized the need of nursing care in the homes of many of her little charges, quickly became interested in Miss Howes’ suggestion.” (For more on the Shaw Day Nurseries see http://bwht.org/shaw.
In addition to learning all they could about the Liverpool organization through visits and an active correspondence with Rathbone and his nursing superintendents, Howes and Adam also studied the situation in Boston. Howes proposed collaborating with the Boston Dispensary, an organization of physicians who had served the poor of the city since 1796. They approached Dr. W. H. H. Hastings, the Superintendent of the Dispensary and he happily agreed to the partnership. Hastings wrote “No one knows better than a Dispensary physician, how hard it is to treat a patient when there is but little to do with, and no one to properly carry out his instructions. He feels powerless, and perhaps suggests a hospital; but that recommendation is declined for fear that it may lead to the breaking up of the home and the scattering of its members. It is in such cases as these that the work of your nurses is needed to complete the efforts of the medical adviser, and accomplish the greatest amount of good for the suffering poor.” (http://en.wikipedia.org/wiki/Boston_Dispensary).
In 1885 Adam became the chairperson of the WEA’s Committee on Industrial Education – and shortly thereafter proposed the idea for District Nursing. Brainard notes that “at first it was necessary to convince the Committee that the work, which at first sight, seemed to partake only of charity, was, in fact largely educational. In this they succeeded, although at first assistance was reluctantly given, and the name “Instructive District Nursing” was adopted in order to ally the work with other educational efforts. By the end of the first year, however, ample proof having been obtained that teaching, as well as nursing, was a large part of the work, the undertaking was heartily endorsed.“
In her report on the activities of the Industrial Education Committee for the year 1885, Adam writes “In concluding our report we desire to express our gratification at the assent of the Association to work we hope to begin with the New Year, and which, for lack of a better name, we call ‘Instructive District Nursing’. It is too early for us to give details of what we propose and hope to accomplish, but, to those who question the acceptance of this work as not within the scope of an Education Association, we desire to say that one of the important portions of the work of a nurse thus employed is as a teacher, and largely consists in the instruction she is able to impart to the family and friends of the patient. Whatever may be the value of lectures on health and on the care of the sick, given to the poor and ignorant, it cannot be doubted that their practical usefulness and assistance must be vastly increased by direct lessons in a sick-room. The skillful application of a simple bandage or poultice at the bedside of a patient reaches at once even the lowest intelligence, and a competent nurse can give instruction of the greatest value in all matters of diet, ventilation, etc – lessons not confined to the immediate sick room, but spreading their beneficial influence throughout the neighborhood in which she works. We ask the interest and cooperation of all the members of the Association, and any suggestions or information bearing upon our work will be gladly received.“
In her April of 1887 report to the WEA Adam, now President of the Instructive District Nursing Association writes – “you will remember that our Association undertook the work of Instructive District Nursing in February 1886, and reports have been read at each meeting of its continued success and the growing interest in the work. At the meeting last April the Committee thought it best to withdraw from the Association, as has been the custom in the past whenever any enterprise had reached the stage when it could stand alone. The President of the new Instructive District Nursing Association reports that it continues to prosper.”
Board of Managers
IDNA – 1887 – Second Year of Operation
Miss Phebe G. Adam
Mrs. F. W. Chandler
Miss A. E. Wheelwright
Miss Hannah A. Adam (sister of Phebe)
Mrs. J.W. Andrews
Mrs. Wm. Appleton
Miss Anne P. Cary
Miss Clara T. Endicott
Mrs. J.S. Copley Green
Miss Margaret Greene
Miss Abbie C. Howes
Miss C.I. Ireland
Miss Mary Minot
Mrs. Oits Norcorss
Miss Mary Russell
Mr. Wm Endicott, Jr.
Dr. Francis Minot
Mrs. Chas D. Homans
Mrs. S. T. Hooper
Dr. Vincent Y. Bowditch
Mr. Lewis Wm. Tappan, Jr.
Mr. George Wigglesworth
First 4 IDNA Nurses Employed By the WEA (7,182 visits to 707 patients were done in the first year)
Amelia Hodgkiss Hired Feb 8, 1886 New England Hospital for Women & Children
(left in November of 1886 after finding the work too stressful)
Elizabeth Rinkler Hired June 15, 1886 Boston City Hospital Training School
Calina E. M. Somerville Hired Nov 1, 1886 Boston City Hospital Training School (went on to become Superintendent of Nurses Lawrence General Hospital)
Emma Gordon Hired May 1, 1887 Boston City Hospital Training School (also travelled to study with Rathbone/Nightingale District Nurses in London)
Thursday, July 28, 2011
We saw in the last post that Rathbone was able to overcome widespread skepticism that any good could come of trying to nurse the sick poor in their own homes when the conditions in these homes were so desperate. He successfully argued that the nurse’s efforts would result in longer lasting improvements if she addressed the environmental problems and the treatment would be less disruptive to the family and community if the patient could be nursed in place. However, there was a second difficulty – how to find enough trained nurses to meet the great need.
Florence Nightingale returned from the Crimean wars in 1856 a highly respected and famous woman. She widely promoted her beliefs about nursing as a profession, including the idea that nurses should receive rigorous training. The first modern nursing school was established at St Thomas’s Hospital in London with the first class of nurses starting in June of 1860. The curriculum was based on Nightingale’s vision of practical nursing skills learned at the bedside, the importance of creating a sanitary environment, the ability to observe the condition of the patient accurately and an emphasis on the strong moral character of the nurse. There was also a course of study including lectures on scientific and medical topics. These nurses were known as “Nightingale Nurses”. They represented a very different type of nurse from the untrained and sometimes unscrupulous women who had been serving as nurses in the poorest districts and the workhouses. The plan was for these trained nurses to establish more schools in hospitals around the country.
At this very time Rathbone was looking for trained nurses to staff his District Nursing organization in Liverpool and wrote to Nightingale in I861 asking how he could find suitable staff. Nightingale responded that it would not be possible to send any of her new nurses to work in Liverpool full time, but that she could send one to Liverpool to establish a training school in the Royal Infirmary. Thus it transpired that Rathbone also became closely involved in nursing training and in seeing that Nightingale’s vision was implemented in training programs throughout the country. This was the first contact in what became a life-long friendship with much correspondence and great mutual admiration between Nightingale and Rathbone based on their shared concern for the well-being of the poor and working classes of Great Britain. Rathbone wrote “in any matter of nursing Miss Nightingale is my Pope and I believe in her infallibility” and that he was “proud to be one of her journeymen workers”. At his death she wrote that he was “one of God’s best and greatest sons.”
In 1881 Florence Nightingale published a booklet entitled “Trained Nursing for the Sick Poor” reflecting on the progress that had been made in the 20 years since District Nursing had begun in Liverpool. The booklet was partly a plea for funding of national training programs with consistent standards and also for homes where district nurses could live together in order to develop an esprit de corps and where their meals and housekeeping would be taken care of, similar to what was provided for nurses who worked in hospitals. She also wrote about the unique nature of District Nursing.
“A District Nurse must first nurse. She must be of a yet higher class and of a yet fuller training than a hospital nurse, because she has not the doctor always at hand; because she has no hospital appliances at hand at all; and because she has to take notes of the case for the doctor, who has no one but her to report to him. She is his staff of clinical clerks, dressers and nurses. These district nurses – and it is the first time that it has ever been done - keep records of the patient’s state including pulse, temperature etc, for the doctor.”
“If a hospital must first of all be a place which shall do the sick no harm, how much more must the sick poor’s room be made a place not to render impossible recovery from the sickness which it has probably bred! This is what the London District Nurses do; they nurse the room as well as the patient, and teach the family to nurse the room.”
“A District Nurse must bring to the notice of the Officer of Health, or proper authority, sanitary defects, which he alone can remedy. Thus dustbins are emptied, water-butts cleaned, water supply and drainage examined and remedied, which looked as if this had not been done for one hundred years.”
“Hospitals are but an intermediate stage of civilization. At present hospitals are the only place where the sick poor can be nursed, or indeed, often the sick rich. But the ultimate object is to nurse all sick at home.“
Thursday, July 14, 2011
Rebecca continues the story of the first Visiting Nurse Association:
Monday, June 20, 2011
Given his familiarity with the situation of the poor citizens of Liverpool, he believed the district nurse would have the greatest impact if she not only attended to the immediate physical ailments of the patient, but also took into consideration their social and family situation as well. His vision was that the nurse would not simply provide short-term relief, but that she would also plant a seed of long-term and widespread improvement by educating the patient and the family to caring for their own sick and instill in them the importance of healthy living and the principles of proper hygiene.
After just one month of work, Robinson asked Rathbone to be released from her contract. Although she was accustomed to sickness and death, the level of suffering and squalor she faced in serving the sick poor of Liverpool was overwhelming. She felt that her efforts were hopeless and were dwarfed by the level of need. Rathbone urged her to continue, and tried to impart in her his belief in the tremendous positive effect her work would have on the lives of those she cared for. “He showed her how much relief from suffering her care brought to the sick; how her teaching and example, must, in time, bear fruit; and that the satisfaction of knowing she had been instrumental in putting even a few families on their feet, and of blazing the path in a new field of work, would compensate her for all her present discouragements” (Brainard, The Evolution of Public Health Nursing, 1922, p 108).
Rathbone’s strong belief in the merits to the plan convinced Robinson, and she continued through her 3 month contract at which time Rathbone’s hopes were fulfilled. She was able to see her success in not only addressing the immediate ailments of the patient, but also in achieving permanent improvements in their health and standard of living. Also, in many cases, the improvement were not limited to the patient, but also their families, whose well being depended on the presence of both a mother and father as caretakers and breadwinners, and also on the community who saw the positive impact on their neighbors and changed their own behaviors. Thus it was at the end of the three month period, Robinson resolved to make district nursing her life’s work.
Rathbone felt confident that his experiment had amply demonstrated the potential benefit district nursing would bring to better the health and stability of those whose grim lives were often shadowed by loss and despair; people who would have otherwise been thought of as hopeless cases. Rathbone was determined to expand the service, but faced several barriers, including the skepticism of his peers. The prevailing opinion was that the problems faced by the multitudes of low-wage workers were insurmountable and that it would be a hopeless exercise for a nurse to try to make a difference. Also, many in the medical community did not believe that proper care could be provided in the busy and dirty conditions of the home and suggested that a hospital was only appropriate venue for care. And, even if Rathbone could convince people to support the project, finding a supply of trained nurses to provide this service throughout the impoverished districts of Liverpool was going to be almost impossible.
Next week we will see how Rathbone overcame these difficulties through a deep and persistent belief in the usefulness of the plan, by widely sharing his enthusiasm for the effort and by turning to Florence Nightingale for help and advice. Rathbone and Nightingale ended up becoming close friends each with a great admiration and respect for the work and ideas of the other.
Saturday, June 18, 2011
Tuesday, June 14, 2011
Next week, I will delve deeper into William Rathbone VI’s achievements and the Liverpool District Nursing organization, arguably his most far reaching effort that has had long term influence on nursing in England and the United States.
Tuesday, June 7, 2011
And he's a nice guy.
Shown here with some of our All-Star VNA of Boston managers...
Friday, June 3, 2011
Here's the next installment from Rebecca...
In this posting, I continue to share the historical insights I’ve been gleaning from reading Annie M. Brainard’s 1922 book, The Evolution of Public Health Nursing. As we enter the 1800s, we observe how the evolution of public health nursing from a service of the Church to a more independent function sets the stage for the entrance of public health nursing as an important component of the modern health care system in the early 1900s.
The Modern Deaconess Movement
It is said that travelers from Protestant countries would return home with stories of the wonderful care given by the Daughters of Charity, the ancient sisterhoods of Beguines and other groups of nursing sisters, the match of which was not to be found in their own countries. So great was the need for similar services that in 1815 an English doctor called for an order of women to be created, who like the Daughters of Charity would be “selected for good, plain common sense, kindness of disposition, indefatigable industry and deep piety; let them receive - not a technical and scientific – but a practical medical education.”
His call was not heeded in England, but in 1822, Theodor Fliedner, a young Lutheran pastor, established a Protestant sisterhood in the German town of Kaiserswerth. Inspired by an order of Mennonite deaconesses he had observed while visiting Holland and also by the work of Elizabeth Fry, a prison reformer in England, Fliedner and his wife created a Women’s Society with the mission of visiting the sick poor in their homes. Like his predecessor Vincent de Paul, he realized that the wealthy ladies interested in giving charity were not particularly suited to the work. So, as with de Paul, he sought out women of the working class with an interest in the vocation of helping the poor and nursing the sick. Fliedner took his organization a step further and provided these women with three years of training before they could be named Deaconess. Fliedner garnered great international respect and his most famous pupil was none other than Florence Nightingale. Nightingale first visited Kaiserwerth in 1846 as a crusading health care reformer, and was so favorably impressed that she later returned to enroll in Fliedner’s program, graduating in 1851.
On a side note, while researching information on deaconesses I stumbled across an article about Boston’s Beth Israel Deaconess Medical Center. I learned that the New England Deaconess Hospital (which later merged with Beth Israel) was founded in 1896 by a group of Fliedner’s deaconesses whose first 14-bed infirmary was opened in a converted five-story brownstone at 691 Massachusetts Avenue, not so far from the VNABA’s office at 561 Massachusetts Avenue (KELLY – I assume we were at 561 in 1896 yes?)
As I continue to study the history of visiting nursing and how the VNABA has grown as an organization, I will be interested to see how the roots of visiting nursing, so steeped in the culture of charity, underlie our modern identity and how we are perceived as a profession. I can’t help feeling that there must be a tension between the business entity we are today and the charitable efforts provided by our predecessors. There is a theme which runs through Brainard’s book; that the modern public health nurse is still animated by the same “spirit of service to mankind” that motivated the early deaconesses and sisters through the centuries. Even though Brainard proposes modern ideas of organization and business she still frames the career of a nurse as more of a calling or vocation rather than simply as a profession or gainful occupation. I am sure this partially reflects the time in which she was writing, but I do wonder how much our modern perception of nursing as a career still harbors an unspoken expectation that the choice to be a nurse goes beyond that of merely choosing an occupation and crosses into the realm of engaging in a “service to mankind” and if so, is there a resultant blurring of the line between the personal and the professional in the role of nurse which still persists today?
Thursday, June 2, 2011
"Make Way for Ducklings" is a fantastic children's picture book, first published in 1941 and written and illustrated by Robert McCloskey. The book chronicles the story of a pair of mallard ducks who decide to raise their family on a small island in the pond at nearby Boston Public Garden.
In October of 1987, a bronze statue depicting Mrs. Mallard and her eight ducklings was placed nearby that same pond. The work was by local artist, Nancy Schon. I understand that there is a similar piece in Moscow (gift of Mrs. Bush to Raisa Gorbachev in 1991).
Through the years, some have had fun with the sculpture, including dressing them up to commemmorate the fact that our Boston Bruins (last night's loss... ugh) are in the Stanley Cup Finals for the first time in over 20 years.
The photo below is a clever photoshop version of the ducks in honor of our great nurses.
Wednesday, June 1, 2011
I had the opportunity to go on home visits with Roberta Dillon, RN, on a hot, humid day last week. Roberta’s “neighborhood” is in the Mattapan area of Boston. As I trailed after her, up the stairs to yet another un-air conditioned apartment, watching as she lugged the tools of her trade, laptop, BP cuff, thermometers and whatever else was carefully packed in her black bag, it hit me again….our clinicians do amazing work and help people who really, really need their expertise.
And again, I wondered at all these initiatives the federal and state governments are putting out there to encourage providers and payers to “contain costs” by coordination of care in less expensive settings. Why not just support (you can read that as “pay fairly”) home health care agencies like the VNA of Boston who do this work and do it extremely well.
Roberta picked me up in the neighborhood and I rode around with her all morning. She knows her way around the community and is a whiz at balancing driving, taking calls (hands free of course, wink), taking notes and keeping it all together – and she doesn’t drive slowly either. Some visits were more complicated than others, watching Roberta work with an older women (96) with dementia, and who was not at all happy with us being in the house, was a tutorial in diplomacy as Roberta convinced her to get a dressing changed that absolutely had to done.
I know we take care of plenty of younger patients, but what struck me was that aging with failing health is a daunting prospect. Aging, and trying to manage the various aspects of the health care you need is an even more daunting prospect. And aging, perhaps with some dementia, and trying to figure out the myriad of caregivers and providers involved in your care looks like it could downright impossible. Even with a constant caregiver in the house, and I met two husbands who could not have been more protective and tender with their wives, those primary caregivers are often not in the best of health either.
That’s where I think the VNA of Boston comes in….Roberta, in more than setting, called the doctor, assessed fall risks, answered questions about the home health aide, reconciled the medications, organized the pharmacy delivery, you name it….she was the manager of the healthcare team. Transitions in care, reducing re-hospitalizations, care coordination, geriatric care management are all buzzwords these days. In my opinion, that wheel does not need to re-invented – it exists at the VNA of Boston and needs to be supported by payers, including the government, not duplicated with all the costs associated with developing new infrastructures. Clone Roberta and others like her -- that may save thousands in a day.
The VNABA Traveling Display recently appeared at the Grove Hall branch of the Boston Public Library. Our thanks to head librarian Paul Edwards, who graciously hosted the event.
I'm pictured next to two nursing students and then on their sides by two of our own nurses, Keren Diamond (far left) and Adele Pike (far right). Carol Bourne, also of the VNA of Boston, is third from the right and librarian, Paul Edwards is next to Adele.
This is part of our effort to celebrate our 125 years of caring out in the community and near those whom we serve...
Tuesday, May 31, 2011
The next installment from Rebecca:
In this posting, I continue to share the historical insights I’ve been gleaning from reading Annie M. Brainard’s 1922 book, The Evolution of Public Health Nursing.
Social Reform in Elizabethan England and the Reformation of the Church
Beginning in the mid-1500s, monasteries, which had been providing care and support for the poor and sick in England for centuries, were dissolved under the English Protestant Reformation. The first Poor Laws, a system of taxation to alleviate the suffering of the “deserving” poor, were put into place by Elizabeth I in 1601. Thus in England, the care of the poor was no longer an individual problem dependent on charity, but had become a national duty. The poor laws were eventually abolished in 1948 when the British National Health service was established.
In the early 1600s, European countries began to emerge from the chaos of the Middle Ages and with that came a renewed recognition of the inequality between the wealthy and the poor. In France, the religious orders were still the primary distributors of charity for the poor, but after the Reformation there was more freedom for the charity to be independent of the strict structure of the monastery system.
In 1633 Vincent de Paul, a German priest, formed a group named the Daughters of Charity, Servants of the Sick Poor. They were a community of women who took simple, private annual vows, were not cloistered, and dedicated their lives to visiting the sick poor. Brainard sees in this group the start of a more organized and systematic approach to the care of the sick poor. de Paul found that while many wealthy women were eager to be of service, they did not really have the skills to care for the sick. He found that all too often they would send their servants in their place, and as such were essentially buying the benefits of charity work. He introduced the idea that charity didn’t have to be the work of just the wealthy, but even those of humble means could partake. He originated the idea of drawing women from the peasant or laboring classes who were desirous of serving their community and who were better suited than their wealthy counterparts to the labor of charity. He oversaw the work of the group, introduced standardization of processes and held regular meetings to stay informed of the caregiver’s progress. de Paul was the first to say progress could not be made without understanding the root causes of poverty and that just giving money to the affected person or community was actually a barrier to self sufficiency.
Monday, May 23, 2011
In this posting, I continue to share the historical insights I’ve been gleaning from reading Annie M. Brainard’s 1922 book, The Evolution of Public Health Nursing. I briefly touch on the Middle Ages and the Protestant Reformation which I’m sure made my eyes glaze over in school, but it is amazing what a little personal interest and application of knowledge does for one’s motivation to learn history!
The Middle Ages and the Institutionalization of Care for the Poor and Sick
Europe in the Middle Ages experienced large differences between the rich and poor, and the progress towards civil society was slowed if not reversed. It was a violent and chaotic time as small groups battled for control of lands, wealth and power. Brainard also notes that there were several centuries of devastating weather patterns, floods and earthquakes resulting in famines and outbreaks of disease including frequent and ravaging epidemics of the Black Plague. It is said that possibly 1/3 to 1/2 of the population of Europe died in the plague of 1348.
It was a dangerous time to be out and about, and the work of visiting the sick poor was largely limited to what noble women could do for the peasants employed on the lands of their husbands. As the years passed, care of the sick poor was centralized to a greater degree and administered by organized institutions such as early hospitals and monasteries. Early hospitals accommodated a wide range of people in need; travelers, locals, the poor and the sick. I would imagine that the wealthy would have availed themselves of private care, perhaps provided by physicians, in their homes.
Brainard mentions a few wealthy women from this era who dedicated their lives to caring for the sick poor and their fortunes to founding hospitals for their care. She tells of Fabiola, a wealthy Roman woman who founded the first hospital in Rome around the year 380. She also writes of Radegund, Queen of France around 550 CE who used the revenues of the lands she was granted at her wedding to establish hospices and to perform other charitable work on behalf of the poor.
Independent Sisterhoods in the Middle Ages
Brainard then covers the advent of sisterhoods that were independent of the formal Church structure. She sees in them the thread of public health nursing that started with the early deaconesses and was carried through the Middle Ages, a time in which there was not much concern for the sick poor. The first of these sisterhoods was the Beguines, a non-monastic, loosely affiliated group started in the late 1100s. They sought to serve God without retiring from the world and resisted the attempts of the church to cloister them and limit their independence. They tended to live on the outskirts of town and made their life’s work caring for the poor. Eventually, larger groups of Beguines came together to live in communities called a Beguinage, where they also built hospitals but they never stopped caring for the sick poor in their homes. By the 1300s the number of Beguines was estimated to be about 200,000. At various times throughout the centuries the church attempted to repress the movement and curtail their independence, but the service they provided to the community, and their desire to perform this role independent of the church, was so strong that the movement persisted.
Brainard mentions several other similar groups in Europe, who, like the Beguines, consisted of women who banded together to serve God by caring for the sick poor in their homes independent of the church. Among them were the Sisters of Mercy, The Sisters of the Common Life, and several others that were aligned with the Protestant Church after the Reformation. However, Brainard points out a couple of weaknesses in the system of independent sisterhoods. There was no central organization overseeing their actions, such as there was in the days of the deaconesses and nursing care was provided by each individual as she saw fit. Also, all too often there was a self-serving element, as visiting the sick poor had become a popular form of penance.
Stay tuned for future installments...
From Janice Sullivan...
The VNABA had a wonderful event last Thursday in Nurses’ Hall at the Massachusetts State House. It was a high visibility location and we got some great community feedback. Thanks to Renard Charity, who represented the Board of the VNABA, and to DeAnne Mignault, an RN on the Downtown team, who made us all proud with her story of why she is a home care nurse and how her patients inspire her every day.
State Senator Sal DiDomenico (second from left) and State Representative Gene O’Flaherty (far right) served as co-hosts of the event. They presented Rey Spadoni with a citation from Governor Deval Patrick in recognition of our 125th anniversary and in appreciation of our commitment to public health nursing in the Boston community.
The traveling display is on the move again and will be at the Grove Hall Boston Public Library branch in Dorchester starting today. All board members and staff, especially those who live or work in the neighborhood, are welcome to join us on Thursday, May 26 at 4 p.m. for a small reception at the library.
Saturday, May 21, 2011
The word "supermom" comes to mind.
Tiffany Goodwin, a Virginia mom, caught this foul ball at a minor league baseball game last Sunday in Richmond. Her 8-month old son, Jerry, seems disinterested. He will, however, be hearing about this photo for the rest of his life.
Ironically, Tiffany's husband, Allen, commented just beforehand that he's been waiting 38 years to catch a ball at the game. He's wearing the blue shirt on the right and as you can see, he's giving it a serious go. But Tiffany made the catch. Good thing she wasn't distracted at the time.
Thursday, May 19, 2011
Here's the first of a four part post from Rebecca regarding the Visiting Nurse Association of Boston (i.e., the visiting nurse/home health) story...
I have a penchant for thoroughness, which in this case means I cannot resist summarizing for you the relevant points of Annie M. Brainard’s 1922 book, The Evolution of Public Health Nursing, in which she traces the roots of the organized visiting nursing profession in England and America from the early Christian movement of the 1st century through the mid-1880s. The points I found relevant are many and so I may have to cover them over a couple of postings as I roll out some of the history behind public nursing.
Having set out to understand the history of visiting nursing, I fear that if I omit recounting this early history we might miss some kernel of information which would help put the course of visiting nursing in perspective. I think that Brainard had a couple of motivations in writing this history in 1922. First, although she acknowledges that “human sympathy and love must have moved people to visit and care for the sick and suffering from the very beginning of time”, she wants to make the point that nursing is a profession, and that public health nursing is a distinct profession within nursing.
Second, she emphasizes that public health nursing is a very different enterprise from private duty nursing even though to the casual observer they appear to involve the same skills. Brainard wrote another book entitled The Organization of Public Health Nursing in which she contrasts the role of the public health nurse with that of the private duty nurse. She argues that the structure of the organization supporting the public health nurse is a crucial part of the success of the entire field of public health nursing. I am eager to read her second book soon as I have a feeling that many of her points will still be relevant today!
Early Roman Christian Society and the First Organized Efforts to Care of the Poor and Sick
Brainard identifies the deaconesses and deacons of the early Christian church as the first organized visiting group. In Greek, the word deacon means “servant” or “helper” and these early Christian devotees strove to serve in accordance with the teachings of Jesus, “I was sick, and you visited me: I was in prison, and you came to me.” (Matthew 25:36, American King James Version).
Deaconesses had a prominent role in serving the community up through the fifth century, when their office was diminished as the church became more established and opportunities for women were increasingly curtailed. Brainard cites from a history of early Christianity that the role of the deaconess was to “Minister to the infirm, to strangers and widows, to be a [mother] to orphans, to go about into the houses of the poor to see if there is anyone in need, sickness or any other adversity, [she] is to care for and give information to strangers; [she] is to wash the paralytic and infirm that they may have refreshment in their pains…[she] is also to visit inns to see if any poor or sick have entered or any dead are in them.”
The work of these early caregivers was steeped in charity and their actions were infused with the principles of self-sacrifice and of giving to those less fortunate. In accordance with their calling as servants of the church they would have shunned personal wealth, would have given away what they had, and when there was greater material need amongst the people, they would have applied to the church for support. Brainard sees in this system of deaconesses and deacons an organization very similar to what developed into the Public Health Nursing profession of her era. The work of the deaconesses was overseen by a central organization and large cities were divided into districts, with each district overseen by a deacon. The major difference between the two eras is that part of the deaconesses’ purpose was to spread the word of Christianity
The system of deaconesses broke down in the middle ages when the Councils of Orange in 441 and Orléans in 533 forbade the ordination of deaconesses. By this time, the popularity of the Christian church had spread far and wide. It had become a wealthy and powerful organization, and such had lost some of the purity of purpose possessed by the early followers of Christ. As we will see in the next post, women of the middle ages wanting to follow Christian teachings often sought other avenues for serving the poor and sick.
Tuesday, May 17, 2011
Governor Patrick testifies to the Joint Committee on Health Care Financing, May 16, 2011
Yesterday, in the Gardner Auditorium at the Massachusetts State House, I had an opportunity to testify to the Joint Committee on Health Care Financing and provide comments regarding Governor Deval Patrick's proposed health care reform bill. It's a bill with far reaching consequences for the entire health industry in the commonwealth, though it provides more in the way of structure and principles than it does in specifics. Nevertheless, industry groups trotted out arguments pro or con and gave, sometimes in painstaking detail, all the reasons the Governor's plan is salvation... or doomed to failure.
I was proud to be the only representative from the home care industry in attendance at the meeting, supporting the efforts of the Massachusetts Home Care Alliance.
Some of the key points made during the day are as follows:
The Patrick Administration: This bill is essential to reigning in costs and to sparking a continued economic recovery in the state. Creating more transparency around reimbursements to providers is essential. Health and Human Service Secretary JudyAnn Bigby, at one point, acknowledged that "home health care providers are underpaid." We agree.
The hospital industry: The bill is too highly regulatory and government-centric in approach. More of a public-private partnership would be more effective. The chronic problem of underpayments by government payers (and the resulting need for hospitals to make up for it elsewhere) is not addressed in the bill, nor the high cost of medical education.
The HMO industry: They touted more of a free-market position and one that capitalizes on what presently works in the system.
Here is the text of my remarks:
Chairman Moore, Chairman Walsh, members of the Committee and staff, I would like to thank you for the opportunity to offer comments today.
I am Rey Spadoni, President of the Visiting Nurse Association of Boston, the very first home care agency in the United States. We are proud to be celebrating our 125th continuous year in operation, serving patients in and around the Boston area. We care for 2,000 patients every day.
We have a long history of responding to public health crises in the Commonwealth of Massachusetts… and of acting as a reliable and unfaltering safety net for our most vulnerable citizens and our most challenged neighbors.
Governor Patrick’s proposed bill and today’s testimony well document the fact that we are experiencing another crisis. We note the facts that Medicare reimbursements per Massachusetts enrollee are among the highest in the nation, we ranks thirty-third on avoidable hospital use and costs… and all this despite the fact that our commonwealth leads the nation in the percentage of residents who have health insurance… at greater than 98% covered.
It is another crisis… and my organization and the Massachusetts home health care industry… is poised once again to become a central and leading voice in developing the solution.
According to the Medicare Payment Advisory Commission, the estimated 2010 cost per day in an acute care hospital approaches $7,000. In home care, it’s $140. When a patient needs to be in a hospital, no other setting will suffice. But when a patient is in the hospital due to avoidable causes, $140 versus $7,000 is a very dramatic difference.
In figures from a study published in the New England Journal of Medicine in 2009, 20% of Medicare enrollees discharged from an acute care hospital are readmitted within 30 days of discharge. According to the researchers, three quarters of those readmissions can be classified as preventable. Readmissions which are estimated to cost our system well over $12 billion each year.
In the United States, 29% of all individuals who receive home care services… and remember that these patients are home bound and already among the sickest of all patients… will be readmitted to the hospital within the 60-day episode of care. At the Visiting Nurse Association of Boston, that number is 25%. That four percent difference, if applied to a larger population, represents a very substantial savings… and opportunity to improve the quality of life, independence and dignity of our sickest and most vulnerable populations. But that four percent difference did not happen by accident. It happened due to investments in technology, clinical centers of excellence that serve patients with chronic disease, staff training and the addition of support services designed to keep people at home and independent or achieving the highest quality of life levels possible for them.
Each day in the hospital, including all the avoidable ones, costs our system $7,000. A day of home care, $140.
Home care can be a central and critical part of solving the health care cost crisis. Innovations and cost saving possibilities here are numerous and should be prominently featured in emerging systems based on accountable or integrated care organizations… and encouraged, not disadvantaged, in new alternative payment methodologies. Without specific and designated representation on the health care innovation advisory committee, health information technology council, and other guiding bodies charged with overseeing the transformation of our state system, I fear we will not fully exploit the opportunities that lie in appropriately deinstitutionalizing the provision of health care services in Massachusetts.
It is the home care industry voice, and perhaps only that voice, that will advance this perspective and help make real this possibility.
Finally, at the Visiting Nurse Association of Boston, we care for residents in every neighborhood in Boston and every patient, regardless of their payer status. We are a valuable part of the delivery system safety net and encourage policy makers to consider the role that organizations such as ours plays in caring for those who, despite 98% insurance coverage in Massachusetts, still fall through the cracks which still do remain.
That has been our mission for the past 125 years. We are ready to carry it into the future.
Thank you. I would be happy to answer any questions you may have.
Wednesday, May 11, 2011
The next installment in the VNA of Boston story from Rebecca...
This week I would like to get back to telling our history --- but I’m struggling with where to begin. One of my goals in writing this blog is to gain an understanding of how the Visiting Nurse Association of Boston & Affiliates (VNABA) became who we are and what it means to be a present day home care organization, so determining exactly where to begin our story is not obvious. To start with the formation of the Instructive District Nursing Association (IDNA ---precursor of the VNABA) in 1886 feels like starting in the middle of the story. Should I start with the Women’s Education Association of Boston, the philanthropic organization which supported the formation of the IDNA? Should I start with the District Nursing organization founded by William Rathbone in England in 1859 upon which the IDNA was modeled? Or do I go all the way back to the first century to the groups of pious women who visited the sick poor in their homes?
As part of my crash course in the history of nursing I have been reading The Evolution of Public Health Nursing (1) written by Annie M. Brainard in 1922. Brainard was the editor of the journal The Public Health Nurse, a lecturer at Western Reserve University and the President of the Visiting Nurse Association of Cleveland in 1913. Her book is frequently cited in publications about visiting nursing and I was convinced to take a closer look because the glimpse I got from the online version at Google Books revealed the most detailed and personal information I had seen about the two women who were behind the creation of the IDNA – Phoebe Adam and Abbie Howes.
The author dedicates ten pages to the history of the IDNA and its founders. These ten pages start on page 203 of a 400 page book --- so by one measure that puts the genesis of our organization at about the halfway mark in the evolution of public health nursing (depending on the source --- also referred to as visiting/district/community nursing). The book provides a detailed account of the various visiting nursing organizations starting in the Roman Empire during the first century and continuing through the Middle Ages, the Age of Enlightenment, the Industrial Revolution, Florence Nightingale and into the early 1900s.
I will share the highlights of our pre-history as presented in this book over the next couple of blogs entries. It is written from a Western European/Christian perspective and as such does not consider the precursors to visiting nursing practice that may have existed in other parts of the world and within other cultures and/or religious traditions. However, I think it remains relevant to the cultural and historical roots of English and American organizations such as Rathbone’s District Nurses and the IDNA.
In closing today here is another poem from the fundraising booklet created by the IDNA nurses and Simmons College students in 1920. The last couple of lines give a sense of the optimism felt by the nurses of what was then the relatively new field of public health regarding the contribution the visiting nurse could make to the prosperity of the country by improving the health of its citizens.
Boost the health centre you attend.
Tuesday, May 10, 2011
For most of my career, I've been fortunate enough to work with clinicians who heal and who care. Who bring skill and experience, and a frequently unquenchable compassion, into situations that many of the rest of us would do nearly anything to avoid. I may be inclined to exit... while they rush in.
Meet Barbara, a nurse manager from the Visiting Nurse Association of Boston. And here are a few of her photos of her native Haiti. Idyllic and beautiful, as in the sunlit bay above. Tragic and devastating, as in what follows.
Tuesday, January 12, 2010. A catastrophic magnitude 7.0 earthquake with an epicenter only 25 kilometers west of capital city, Port-au-Prince. Ultimately... 316,000 dead. 300,000 injured. 1,000,000 homeless.
And Barbara rushed in.
Here's her story... from the beginning.
Barbara grew up in Carrefour, a suburb of Port-au-Prince, with her mom, a teacher, and dad, an owner of an auto repair business, and brother and sister. It was a happy, largely uneventful time... until her father became sick. Among his ailments, Barbara's father also suffered from decubitius skin ulcers, which then (and even still today in Haiti) were poorly understood. Barbara, then 13 years old, remembers being angry when her father, a proud man who resisted family pressure to move to the United States, told her "not to worry" and that he would be around for "another ten years". Unfortunately, that was not to be the case.
At the age of 16, Barbara and her remaining family members moved to Florida and then eventually to Cambridge, Massachusetts. Barbara and her sister, Beatrice, held a variety of jobs and when Barbara decided she wanted to become a nurse, Beatrice, then a medical assistant, helped her to pay for the training. When Barbara completed nursing school, she began working and then helped to finance Beatrice's nursing education. Barbara continued on to earn her bachelor's degree and is now studying for a master's in health care administration.
Barbara remembers well that day in January, 2010. Reports of an earthquake began surfacing, with no one fully aware of its magnitude or impact. Beatrice called Barbara and gave her an update. It was far worse than expected. Far worse.
Barbara recalls: "We were looking at the news. We couldn't believe it. Nobody knew what was happening. We started calling our family there but no lines were open. We were so worried. We couldn't sleep. We tried calling the UN but couldn't get through. We just didn't know what to do. I was desperate..."
The overwhelming emotion was helplessness. "People there were dying and I thought, I'm a nurse. I have to help." Partners in Health, an organization dedicated to improving the quality and access to health care services in poor and developing areas, called Beatrice on Saturday and asked to deploy her to Haiti on the following Monday. A month later, Barbara's call came.
It was a two week assignment. The lead time was limited. According to Barbara, "you just pack your bag and go."
She recalls departing the airport in Haiti. She remembers looking around at the rubble, the devastation, the places where buildings once stood. "It was tough to see a country you left and is no longer there."
Barbara was stationed at the General Hospital in Port-au-Prince. "Once you got there, the gate was closed and you couldn't leave." And once there, she and her companions worked for 10 days straight, during 7PM to 7AM shifts. Barbara remembers being struck when she saw the former sight of a nursing school next to the hospital which she had seen as a child. "It was no longer there. It was completely flat. I wondered how many people were trapped underneath."
After a quick orientation from the physician-in-charge, Barbara was given a brief tour and was immediately "put to work." She described the first day as "one of the worst days of my life. There were 300 to 400 patients there all needing care... from TB to fractures to missing limbs to wounds... to people who were just dying. Just name it - it was right there looking at you..."
When asked how she responded to that, Barbara describes: "You start to work. Your forget about everything else. You just tried to save everyone you could. You just do whatever you can."
She remembers one young girl at the hospital. She had lost nine members of her family in the tragedy. "She was so thin. You could see only bones. She would not eat or drink... and she never spoke... except at night, she would scream out the names of her family who were now lost to her. I remember seeing a lady who stayed with her. She was from the local church and she slept on the floor, giving the girl a sip of water." Despite their efforts, the patient passed away.
Another patient, a 27 year old woman with renal failure and high blood pressure, was experiencing significant physical and emotional stress. Barbara knew the patient needed oxygen and fast, so she ran down the hall looking for a tank. A simple tank of oxygen. Plentiful in every hospital where Barbara has worked, but scarce in Port-au-Prince's General Hospital. Barbara called out: "This girl's going to die, her heart's going to give out soon... "... and remembers seeing the desperate look in the woman's eyes. The patient said to Barbara: "Please don't leave me. If you leave me, they're going to let me die." Barbara knew she was right.
The patient eventually received the oxygen and the vital dialysis she required and lived.
There was also an older woman patient who "could have been my mother." She had two wounds in her lower legs; "it looked to be a diabetic ulcer". Barbara watched this patient fade from an amiable, even joking, favorite among the nurses, to one who became more and more ill and despondent. At one point, she had no clothing or even sheets, leaving one of the nurses to donate some of her own clothing to the patient. The patient died, alone and in pain. Per Barbara, "there was no reason for her to die that way..."
Barbara looks back at the experience and feels that: "We didn't do enough. There's so much more to do there. And it's not over there. It's terrible what's happening in the tent cities there now. It's just horrible still... but I want to go back."
When asked why she wants to return, Barbara lowered her eyes and said, simply and solemnly: "It's what we do... we are nurses..."
If you're interested in learning more about Partners in Health, please click here.
If you'd like to help, click here.
Posted by Rey
Monday, May 9, 2011
This week, we celebrate National VNA Week and acknowledge and celebrate the invaluable work we do to keep patients home, where they most want to be. It’s even more special this year because we also are celebrating 125 years of providing excellent care for our community. We have a proud history and we can look forward to our future…. the VNA of Boston & Affiliates is more relevant now than ever before.
We are there at the start of life and we are there at the end of life providing compassionate care so that patients have the best quality of life they can with dignity and independence. Here is a sampling of some of the comments we receive from our patients:
“VNA of Boston is consistently excellent! VNA has improved my quality of life & sense of wellness!!!”
“I was treated with the greatest respect and courtesy.”
“They made me feel safe and secure in helping me get better and made a good recovery in regaining my health back.”
“We have had multiple experiences - OT's, PT's, nurses - all have been great.”
“I was very impressed with the professionalism of all who helped me. Thank you very much!”
“The care was excellent and I would highly recommend the VNA to anyone. Everyone was great.”
Thank you all – to all the clinicians in the field and the staff in the office who support their work – for your expertise, your passion and commitment, and your contribution to the future of the VNA of Boston & Affiliates.
Thursday, May 5, 2011
As I dig deeper into the agency’s history I am finding more and more information on the partnership between the VNAB and Simmons College. The two started cooperating in 1912 to offer academic coursework specifically for Public Health nurses. Simmons’ Department of Public Health Nursing was established in 1916 under the direction of Anne Hervey Strong, and in 1918 a full-fledged School of Public Health Nursing was created and run jointly by the Instructive District Nurse Association (known today as the VNA of Boston) and Simmons College.
This week, I would once again like to share something I found in the Simmons archive with much appreciation to an author from the past. The article, entitled Nursing by Leg Power (see below - apologies that it's a bit hard to read; if you click on the graphic, it will open in another window and may be easier to read) by Dorothy Deming, was published in November of 1929 in a journal titled The Survey. The Survey started as an in-house publication of the New York Charity Organization Society in 1902 and under the editorial direction of Paul U. Kellogg it became the “most eloquent and revered voice of the social justice wing of the twentieth-century American reform movement“until it ceased publication in 1952. (See note.)
I immediately liked the article as it is quite humorous. The author also artfully weaves in a wealth of information about what a Public Health Nurse is, what she does, how she is trained and the nuts and bolts of her vocation. Again, it is interesting to note the similarities with today’s visiting nurse experience…the challenge of defining exactly what a visiting nurse is, the diversity of cases seen, the complications of reimbursement, the extent to which education needs to be tailored for the visiting nurse and of course the uniform… just kidding! (I’m not so sure about the illustration comparing a visiting nurse to a mother monkey… but I guess in 1929, evolution was still a somewhat radical concept!)...