555
PUBLIC HEALTH NURSING'S RESPONSIBILITIES FOR THE CARE OF THE AGED* DORIS R. SCHWARTZ, R.N., M.A. Associate Professor of Nursing Cornell University-New York Hospital School of Nursing New York, New York Co-Director, Geriatric Nurse Practitioner Program The Burke Rehabilitation Center White Plains, New York
To explore the relations of older people to public nurses and to consider public health nursing's responsibilities for the health care of the elderly today, it is important to define some terms. We need to consider the scope of nursing and public health, the needs of the well elderly and the chronically ill elderly, and the responsibilities of older people themselves as consumers of health care. We must differentiate between services which are available to all the elderly who can profit by them and imaginative public health nursing programs which are available only in limited geographic areas or are offered only to selected groups of people. We need to distinguish between what public health nurses believe should be done and what we are actually doing, between the educational philosophy and preparation of the public health nurse and the realities of practice. Had I prepared this paper from the viewpoint of the most socially conscious public health nurses in New York City and illustrated it with examples of their practices and the policies of their employing agencies, the paper would give me pleasure to write and would give you joy and encouragement to read. I could show you these services with pride and I know that you would view them with enthusiasm for they are very good indeed and occur daily. Both the agents and recipients of care are well satisfied with them. However, if you were to visit a random sample of old people in our city, state, or nation-especially a stratified random sample or one from lower socioeconomic classes or minority cultural groups-and talk with them of their met and unmet needs, you would find a great gulf *Presented as part of a Symposium on Geriatric Medicine held by the Section on Geriatric Medicine of the New York Academy of Medicine and the American Geriatrics Society at the Academy June 8, 1977.
Vol. 54, No. 6, June 1978
556
55
D. SCHWARTZ
D. SCWAT
between what we know how to do and what we are doing for most of the elderly. You would become skeptical of the attractive picture I had painted, and would be able to point out many defects. This is our dilemma and, perhaps, the dilemma of every health profession in its work, though the reasons differ. Much of what we know how to do is on library shelves or is being done chiefly in experimental programs. Large segments of even the simplest truths and services fail to reach those most in need of preventive and curative services.2 According to the 1970 census, there were approximately 20 million Americans 65 years of age or older, one million of whom were living in institutions.3 The remaining 19 million require health services in their local communities. In the years ahead the absolute number and proportion of people 65 years and older in the population will increase because of gains in life expectancy and the declining birth rate. In a pamphlet prepared for the International Council of Nurses, V. Henderson defines nursing as follows:4 The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health, or its recovery, (or to a peaceful death) that he would perform unaided, if he had the necessary strength, will or knowledge. And to do this in such a way as to help him regain independence as rapidly as possible.
Concepts of public health deal with communities; the practice of public health, especially the practice of public health nursing, deals with persons. Thus, a public health nurse is privileged to view health problems and needs as these occur in population groups and to establish priorities in program planning based upon these observations. Because public health nursing services are centered around individuals and families, when the nurse becomes an emissary in delivering geriatric services she carries them to the peoples' natural habitat: the home, the community, the "substitute home"' of the geriatric day center, and, increasingly, the nursing home. Perhaps no investigator of aging understands the needs of the elderly in sickness and in health better than sociologist Ethel Shanas.5 Public health nurses greatly respect her because she categorizes health needs much as they do. She recognizes that limitations on their ability to function concern old people more than the label of the disease responsible for their disability: thus, an 88-year-old blind woman living alone would state her problem as "I can't see." Her physician must determine whether glaucoma, trachoma, trauma, cataract, or another condition is responsible and what, if anything, can be done about it. The public health nurse, with the help of Bull. N.Y. Acad. Med.
PUBLIC HEALTH NURSING
557
557
the patient, must synthesize these two approaches into an acceptable plan for daily living by considering need, availability, and accessibility of service, therapeutic recommendations, and the presence or absence of significant people to help. She must help this old lady to make herself and her environment safe and support her decisions to live each day as well as her potential permits. Public health surveys often tell us important facts about the incidence and prevalence of pathological conditions, while Shanas uses functional divisions such as fully ambulatory, partially ambulatory, homebound, chairbound, and fully-dependent old persons.5 These divisions better reflect the concerns of public health nurses in working with the aged. One trend has become apparent: our society is geared toward automation and tends to centralize health care. Older people, except those requiring dramatic life-preserving services, are seldom well served by centralization. They prefer and fare better with health care that emphasizes continuity, local services, preventive teaching, early detection of changes, and effective monitoring of chronic illness. Primary-practice nurses serve populations of patients, including the very old, in such settings as rural clinics, geriatric day centers, single-room-occupancy residences, homes of the chronically ill-acting as the primary health-care contact and maintaining a collaborative relation with a physician or hospital clinic.6"l0 The dual interest of the public health nurse for the health of the population and the individual focuses on five stages of illness, in each of which she has an important responsibility for planning and doing. I first learned of this staged approach to thinking about a patient or a problem from Dr. George James, so I shall paraphrase and summarize his view of concepts found in any good public health textbook. The first stage is purely preventive: preservation of existing health, both physical and mental. Many programs of public health nursing have this as their primary aim. In working with old people, it includes a wide range of areas of health teaching: safety, the various crises of aging, life tasks of the later stages of life, and ways of maintaining maximum physical health. It is essential in this work to recognize barriers which require removal. Avenues of,,empathy and imagination must be opened to approach the experience of all old people, the experience of facing up to a series of existing or potential losses. The second stage is also preventive, and deals with the segment of the older population at special hazard for a variety of reasons: genetic defect, Vol. 54, No. 6, June 1978
55855
D. SCHWARTZ D. SCWAT
poverty, early deprivation of opportunity for normal growth and development, or lack of adequate facilities, knowledge, or motivation to reach out for appropriate help. The third stage is concerned with the early detection of existing problems when remedial steps are relatively simple or of great consequence. These problems include both physical and mental or emotional malfunctions. The fourth stage is that of manifest illness, often chronic in this age group and with acute exacerbations toward which most hospital nurses direct their greatest efforts. As medical knowledge advances and technology permits ever greater saving of life by clinical judgement, an increasing portion of our total nursing force is found at the bedsides of acutely ill patients, where heroic measures have become commonplace. Understandably, then, the care of other patients becomes impoverished by the quantity and quality of nurses drained off from the total supply for this use. As Dr. James used to remind us, the horizontal (bedridden) patient nearly always gets more and better care than the vertical (ambulatory) patient.6 This requires a change of emphasis. The fifth stage, rehabilitation, is often received as a discrete phase with special skills and goals. Yet, in practice, the effective care of patients implies the use of rehabilitative concepts and techniques from the moment an individual is first recognized as a patient. The public health nurse-whether she works in family-centered programs of care or her full time is devoted to the care of old people-should lead in improving geriatric care in the community. Increasingly, public health nurses are seeking additional preparation to give direct preventive, curative, and maintenance services to older people. This is an alternative to full-time institutional care for the older, chronically ill, or disabled individual who, with appropriate help, can live within his home and family. To provide this care, a public health nurse must have basic knowledge of the concepts and practices of rehabilitation nursing, gerontology, the prevention and management of common chronic diseases, general nursing, public health practice-including teaching skills,-and an understanding of simple evaluative principles and techniques. In addition, she must understand healthy aging as different from illness superimposed on aging and grief and grieving. Whether she is teaching patients, families, or auxiliary health workers, her influence on the care of the elderly has considerable Bull. N.Y. Acad. Med.
PUBLIC HEALTH NURSING
559
scope.9 Within the past decade perhaps several thousand nurses have added to their skills by additional study to qualify for greater responsibility in providing primary care. Perhaps 150 to 200 of these nurses have graduated from programs preparing geriatric nurse-practitioners exclusively. Others who graduated from programs preparing family or adult-health nurse-practitioners have chosen positions where all or most of their time and energy is spent in geriatric practice. Although these specially trained nurses now represent a tiny percentage of all public health or other nurses caring for geriatric patients, they already have shown that in association with a physician they can assume responsibility for many patients in practices where general medical services are needed. Nurses with this additional training in primary care generally are called nurse-practitioners and are eligible to take a national certifying examination.8'9 In a consultative role the public health nurse, particularly if she has a practitioner's skills, can perform many functions. She can promote clinics in housing developments and other communities of the elderly. She can assist boarding and nursing homes in planning appropriate daily activities while taking direct responsibility for selected patients. She can become an advocate for the elderly, whether through membership in an interdisciplinary health team or through participation in organized home-care programs. She can collaborate with community multiphasic screening schemes and if she is in primary practice she can manage a case load of older patients collaboratively with a clinic or private physician.8"l'' To work effectively with limited long-term goals amid some degree of public apathy (as anyone must) and to be effective in geriatrics or gerontology a nurse needs commitment and endurance, which, combined with adequate knowledge, can forcefully influence society's attitudes toward the aged, improve health services, and offer a rewarding career in health care." REFERENCES 1. Annual Report. New York, Visiting 4. Henderson, V.: The Nature of Nursing. Nurse Service of New York, 1976. New York, Macmillan, 1966. 2. Schwartz, D., Henley, B., and Zeitz, L: 5. Shanas, E., Townsend, P., WedderThe Elderly Ambulatory Patient: Nursburn, D., et al., Oldf People in Three ing and Psychosocial Needs. New York, Indlustrial Societies. London, Routledge Macmillan, 1963. 3. Bureau of the Census: Pocket Data Book. Publication No. 0324-00109. Washington, D.C., Govt. Print. Off., 1973.
Vol. 54, No. 6, June 1978
and Keegan, 1968. 6. James, G.: Poverty as an obstacle to health progress in our cities. Am. J. Public Health 55: 1757-71, 1965. 7. Workshop for students of nursing, the
560
D. SCHWARTZ
Cornell University-New York Hospital School of Nursing, New York, N.Y. 1965. Personal communication. 8. Roueche, B., editor: Together. Chicago, Nat. Joint Practice Comm., 1977. 9. American Nurses Association; Guidelines for Short- Term Continuing Education Programs, Preparing the
Geriatric Nurse Practitioner. Kansas City, 1974. 10. Sultz, H., Zielenzny, M., and Kinyon, L.: Longitudinal Study of Nurse Practitioners: Phase I H. E.W. Publication No. 017-0011-4. Washington, D.C., Govt. Print. Off., 1977.
Bull. N.Y. Acad. Med.
PUBLIC HEALTH NURSING'S RESPONSIBILITIES FOR THE CARE OF THE AGED* DORIS R. SCHWARTZ, R.N., M.A. Associate Professor of Nursing Cornell University-New York Hospital School of Nursing New York, New York Co-Director, Geriatric Nurse Practitioner Program The Burke Rehabilitation Center White Plains, New York
To explore the relations of older people to public nurses and to consider public health nursing's responsibilities for the health care of the elderly today, it is important to define some terms. We need to consider the scope of nursing and public health, the needs of the well elderly and the chronically ill elderly, and the responsibilities of older people themselves as consumers of health care. We must differentiate between services which are available to all the elderly who can profit by them and imaginative public health nursing programs which are available only in limited geographic areas or are offered only to selected groups of people. We need to distinguish between what public health nurses believe should be done and what we are actually doing, between the educational philosophy and preparation of the public health nurse and the realities of practice. Had I prepared this paper from the viewpoint of the most socially conscious public health nurses in New York City and illustrated it with examples of their practices and the policies of their employing agencies, the paper would give me pleasure to write and would give you joy and encouragement to read. I could show you these services with pride and I know that you would view them with enthusiasm for they are very good indeed and occur daily. Both the agents and recipients of care are well satisfied with them. However, if you were to visit a random sample of old people in our city, state, or nation-especially a stratified random sample or one from lower socioeconomic classes or minority cultural groups-and talk with them of their met and unmet needs, you would find a great gulf *Presented as part of a Symposium on Geriatric Medicine held by the Section on Geriatric Medicine of the New York Academy of Medicine and the American Geriatrics Society at the Academy June 8, 1977.
Vol. 54, No. 6, June 1978
556
55
D. SCHWARTZ
D. SCWAT
between what we know how to do and what we are doing for most of the elderly. You would become skeptical of the attractive picture I had painted, and would be able to point out many defects. This is our dilemma and, perhaps, the dilemma of every health profession in its work, though the reasons differ. Much of what we know how to do is on library shelves or is being done chiefly in experimental programs. Large segments of even the simplest truths and services fail to reach those most in need of preventive and curative services.2 According to the 1970 census, there were approximately 20 million Americans 65 years of age or older, one million of whom were living in institutions.3 The remaining 19 million require health services in their local communities. In the years ahead the absolute number and proportion of people 65 years and older in the population will increase because of gains in life expectancy and the declining birth rate. In a pamphlet prepared for the International Council of Nurses, V. Henderson defines nursing as follows:4 The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health, or its recovery, (or to a peaceful death) that he would perform unaided, if he had the necessary strength, will or knowledge. And to do this in such a way as to help him regain independence as rapidly as possible.
Concepts of public health deal with communities; the practice of public health, especially the practice of public health nursing, deals with persons. Thus, a public health nurse is privileged to view health problems and needs as these occur in population groups and to establish priorities in program planning based upon these observations. Because public health nursing services are centered around individuals and families, when the nurse becomes an emissary in delivering geriatric services she carries them to the peoples' natural habitat: the home, the community, the "substitute home"' of the geriatric day center, and, increasingly, the nursing home. Perhaps no investigator of aging understands the needs of the elderly in sickness and in health better than sociologist Ethel Shanas.5 Public health nurses greatly respect her because she categorizes health needs much as they do. She recognizes that limitations on their ability to function concern old people more than the label of the disease responsible for their disability: thus, an 88-year-old blind woman living alone would state her problem as "I can't see." Her physician must determine whether glaucoma, trachoma, trauma, cataract, or another condition is responsible and what, if anything, can be done about it. The public health nurse, with the help of Bull. N.Y. Acad. Med.
PUBLIC HEALTH NURSING
557
557
the patient, must synthesize these two approaches into an acceptable plan for daily living by considering need, availability, and accessibility of service, therapeutic recommendations, and the presence or absence of significant people to help. She must help this old lady to make herself and her environment safe and support her decisions to live each day as well as her potential permits. Public health surveys often tell us important facts about the incidence and prevalence of pathological conditions, while Shanas uses functional divisions such as fully ambulatory, partially ambulatory, homebound, chairbound, and fully-dependent old persons.5 These divisions better reflect the concerns of public health nurses in working with the aged. One trend has become apparent: our society is geared toward automation and tends to centralize health care. Older people, except those requiring dramatic life-preserving services, are seldom well served by centralization. They prefer and fare better with health care that emphasizes continuity, local services, preventive teaching, early detection of changes, and effective monitoring of chronic illness. Primary-practice nurses serve populations of patients, including the very old, in such settings as rural clinics, geriatric day centers, single-room-occupancy residences, homes of the chronically ill-acting as the primary health-care contact and maintaining a collaborative relation with a physician or hospital clinic.6"l0 The dual interest of the public health nurse for the health of the population and the individual focuses on five stages of illness, in each of which she has an important responsibility for planning and doing. I first learned of this staged approach to thinking about a patient or a problem from Dr. George James, so I shall paraphrase and summarize his view of concepts found in any good public health textbook. The first stage is purely preventive: preservation of existing health, both physical and mental. Many programs of public health nursing have this as their primary aim. In working with old people, it includes a wide range of areas of health teaching: safety, the various crises of aging, life tasks of the later stages of life, and ways of maintaining maximum physical health. It is essential in this work to recognize barriers which require removal. Avenues of,,empathy and imagination must be opened to approach the experience of all old people, the experience of facing up to a series of existing or potential losses. The second stage is also preventive, and deals with the segment of the older population at special hazard for a variety of reasons: genetic defect, Vol. 54, No. 6, June 1978
55855
D. SCHWARTZ D. SCWAT
poverty, early deprivation of opportunity for normal growth and development, or lack of adequate facilities, knowledge, or motivation to reach out for appropriate help. The third stage is concerned with the early detection of existing problems when remedial steps are relatively simple or of great consequence. These problems include both physical and mental or emotional malfunctions. The fourth stage is that of manifest illness, often chronic in this age group and with acute exacerbations toward which most hospital nurses direct their greatest efforts. As medical knowledge advances and technology permits ever greater saving of life by clinical judgement, an increasing portion of our total nursing force is found at the bedsides of acutely ill patients, where heroic measures have become commonplace. Understandably, then, the care of other patients becomes impoverished by the quantity and quality of nurses drained off from the total supply for this use. As Dr. James used to remind us, the horizontal (bedridden) patient nearly always gets more and better care than the vertical (ambulatory) patient.6 This requires a change of emphasis. The fifth stage, rehabilitation, is often received as a discrete phase with special skills and goals. Yet, in practice, the effective care of patients implies the use of rehabilitative concepts and techniques from the moment an individual is first recognized as a patient. The public health nurse-whether she works in family-centered programs of care or her full time is devoted to the care of old people-should lead in improving geriatric care in the community. Increasingly, public health nurses are seeking additional preparation to give direct preventive, curative, and maintenance services to older people. This is an alternative to full-time institutional care for the older, chronically ill, or disabled individual who, with appropriate help, can live within his home and family. To provide this care, a public health nurse must have basic knowledge of the concepts and practices of rehabilitation nursing, gerontology, the prevention and management of common chronic diseases, general nursing, public health practice-including teaching skills,-and an understanding of simple evaluative principles and techniques. In addition, she must understand healthy aging as different from illness superimposed on aging and grief and grieving. Whether she is teaching patients, families, or auxiliary health workers, her influence on the care of the elderly has considerable Bull. N.Y. Acad. Med.
PUBLIC HEALTH NURSING
559
scope.9 Within the past decade perhaps several thousand nurses have added to their skills by additional study to qualify for greater responsibility in providing primary care. Perhaps 150 to 200 of these nurses have graduated from programs preparing geriatric nurse-practitioners exclusively. Others who graduated from programs preparing family or adult-health nurse-practitioners have chosen positions where all or most of their time and energy is spent in geriatric practice. Although these specially trained nurses now represent a tiny percentage of all public health or other nurses caring for geriatric patients, they already have shown that in association with a physician they can assume responsibility for many patients in practices where general medical services are needed. Nurses with this additional training in primary care generally are called nurse-practitioners and are eligible to take a national certifying examination.8'9 In a consultative role the public health nurse, particularly if she has a practitioner's skills, can perform many functions. She can promote clinics in housing developments and other communities of the elderly. She can assist boarding and nursing homes in planning appropriate daily activities while taking direct responsibility for selected patients. She can become an advocate for the elderly, whether through membership in an interdisciplinary health team or through participation in organized home-care programs. She can collaborate with community multiphasic screening schemes and if she is in primary practice she can manage a case load of older patients collaboratively with a clinic or private physician.8"l'' To work effectively with limited long-term goals amid some degree of public apathy (as anyone must) and to be effective in geriatrics or gerontology a nurse needs commitment and endurance, which, combined with adequate knowledge, can forcefully influence society's attitudes toward the aged, improve health services, and offer a rewarding career in health care." REFERENCES 1. Annual Report. New York, Visiting 4. Henderson, V.: The Nature of Nursing. Nurse Service of New York, 1976. New York, Macmillan, 1966. 2. Schwartz, D., Henley, B., and Zeitz, L: 5. Shanas, E., Townsend, P., WedderThe Elderly Ambulatory Patient: Nursburn, D., et al., Oldf People in Three ing and Psychosocial Needs. New York, Indlustrial Societies. London, Routledge Macmillan, 1963. 3. Bureau of the Census: Pocket Data Book. Publication No. 0324-00109. Washington, D.C., Govt. Print. Off., 1973.
Vol. 54, No. 6, June 1978
and Keegan, 1968. 6. James, G.: Poverty as an obstacle to health progress in our cities. Am. J. Public Health 55: 1757-71, 1965. 7. Workshop for students of nursing, the
560
D. SCHWARTZ
Cornell University-New York Hospital School of Nursing, New York, N.Y. 1965. Personal communication. 8. Roueche, B., editor: Together. Chicago, Nat. Joint Practice Comm., 1977. 9. American Nurses Association; Guidelines for Short- Term Continuing Education Programs, Preparing the
Geriatric Nurse Practitioner. Kansas City, 1974. 10. Sultz, H., Zielenzny, M., and Kinyon, L.: Longitudinal Study of Nurse Practitioners: Phase I H. E.W. Publication No. 017-0011-4. Washington, D.C., Govt. Print. Off., 1977.
Bull. N.Y. Acad. Med.
