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!)...