Utah Nurse

Utah Nurse: The Official Publication of the Utah Nurses Association. Utah Nurse has been published quarterly since 1946 for the Utah Nurses Association, a constituent member of the American Nurses Association. Sent to RNs and LPNs throughout Utah, Utah Nurse provides a forum for members to express their opinions and become aware of healthcare issues in the state of Utah.

BULK RATE U. S. POSTAGE UTAH NURSE PAID Salt Lake City, Utah Perm it Na. 1882 .. ~ OFFICIAL PUBLICATION OF UTAH STATE NURSES ASSOCIATION Summer, 1969 • Vol. 20, No. 2 God who gave us life gave us liberty. Can the liberties of a nation be secure when we have removed a conviction that these liberties are the gift of God? Indeed I tremble tor mY country when I reflect that God is ;ust. That His ;ustice cannot sleep forever. commerce between master and slave is despotism. Nothing is more certainly written in the Book of Fate than that these people are to be tree. Establish the law tor educating the common people. That is the business of the State to effect and on A GENERAL PLAN I am not an advocate tor frequent changes in laws and institutions must go hand in hand with the progress of the human mind. As that becomes more developed. More enlightened. As new discoveries are made. New truths discovered and manners and opinions change. With the change of circumstances. Institutions must advance also to keep pace with the times. We might as well require a man to wear still the coat which titted him when a bDY as· civilized society to remain. Ever under the regimen of their barbarous ancestors. THOMAS JEFFERSON MEMORIAL Wherever you go ! Where friends meet, Remember ..... . - Vol. 20 S Off Utah Sta 42 S Salt La P Executive Ed 42 Salt La Editor _____________ 246 Salt La A Part of the Fun A 1007 Salt La 306 DATES September 11 Gf "( Sp M 13 c~ 18 Di -ef Ill Bi 24-25 I w ta October 10 u 24-25 "] c la .Vovember 1 20 G A P. " ti February 6 ·' 1 25 p 4-8 } 21-23 1 May ~ THE COCA-COLA BOTTLING COMPANY OF SALT LAKE I Summer, 19 KE Vol. 20 Summer, 1969 No. 2 Official Publication of the Utah State Nurses' Association 42 South Fifth E ast Salt Lake City, Utah 84102 Phone [phone] Executive Editor ...... Corallene M cK ean 42 South 5th East Salt Lake C ity, U tah 84102 Editor................................Edna Neu m ann 2469 Cavalier Drive Salt Lake City, U t ah 8412 1 ASSISTANTS Annetta J. Bilger 1007 East South T emple Salt Lake City, Utah 84102 Marilyn L yons 306 South 400 E ast Provo, Uta h DATES TO REMEMBER 1969 September 11 Geriatrics Workshop "Competent Patient Care' Speaker, Dr. Wa lters Moreau H all 13 Careers Workshop - Mor-eau Hall 18 District # 1 Dinner M eeting University of Utah Building 24-25 Infec tion Control Workshop - LDS H ospital October 10 U.E.A. & U .S.N.A. Conference 24-25 "Practical Politics" L egislative Committee An interesting phenomenon has been attributed to the nursing profession: that we hate to sec our colleagues get ahead . One could argue the accuracy of such a charge, but most experienced nurses can think of many examples to substantiate the allegation. They range all the way from not volunteering the location of the linen room, to discouraging a bright master's degree nurse from continuing in a doctoral program. At this time of year when new ,g raduates are taking first positions, the phenomenon - to whatever degree it does operate - can be espe:·ially influential. What quality is probably most important in combating the affects of this subtle discouraging, undermining attitude? The core is courage. It takes courage for the experienced, older nurse to listen to ideas espoused by the young, new graduate. More courage is required to solicit her fresh ideas and current knowledge. Courage is needed to hold back flippant remarks about a difficult patient, courage to make positive comments when the other team members are being negative. Courage is also needed by the young nurse. Courage to be flexible in hrr practice, to close her lips on "but we were taught to do it this way," to watch and learn before condemning. Courage is a vital commodity in nursing. Certainly for those rare times of crisis, but also and perhaps more because the dramatic quality is absent, in those nursing situations which seem ordinary. ----~--Edna L. Neumann STUDENT ACTIVITIES Schedule of Planned SNAU Events: Workshops: October - Holy Cross Decem ber - Charity D rive M onth February - U niversity of U tah M arch - St. M arks May - BYU or Weber -:f \'ovember 1 Geriatrics Workshop 20 Administrative - Nurse Physician Confe rence "Colleagues in Collaboration For Care" 1970 February 6 "Human R esources Workshop'' 25 Public H ealth Workshop .\fay 4-8 A.N.A. Convention Miami, Florida 21-23 U.S.N.A. Convention Park City, Utah Summer, 1969 EDITORIAL C: onventions: Friday, November 7th Friday, April 10th N ext M eeting : (Executive Council ) September 16th - 7 : 00 p.m. Holy Cross Nursing School * Each School sets up its own da te a nd time well in adva nce. This is to discourage us from having th em a t the same time all the year. Robbie Fox, Presiden t TABLE OF CONTENTS Page Dates tu R emember ... ........... ........... .. 3 Student Activities ..... ... ...... ................. . 3 Editori al ......................... ... ......... ...... .. Edna L . N eumann 3 Community H ealth Nursing D es tina tion- Freewa y or D etour .... ..4-1 0 D oris Wagn er " A urse's Aid e" in the H ead Sta rt Program ....... ... ....... ......... 10 Elma H umphreys Pain ........ .................... ........... ..... ...... 11-1 5 U .S. Pub lic H ealth Service Acc redita t ion- Community Nursing Services ...... .. .. ....... .................... ....... 16 Elec ted Officials .... ..... ...... ............ .. . 18-1 9 H ypnosis D emonstra ted ......... ....... ...... 20 D istrict #6 Edu cationa l Oppor tun ity ......... ...... ..... 20 H ealth Agencies R ole in Support of the Nurse Practice Act ... .. ........... 2 1-22 E va Jean Law U .S .N .A. R esponsibili ties a nd The Nurse Practi ce Act ...................... .... 22 Corallene McKean " Prosp ects for Practice" ................. ..... 2 2 A.N.A. Clincial Conferences Genetics ........ ... ...... .. ....... ...... .. .......... 23-24 Civil R ights Act 187 1 ...... .................. 24 Public H ealth Nursing Today .... ........ 25 Ruth D eRisi Expa nsion- The Scheme ... ....... ... ... 26-28 E va Jean Law M odel Stroke Unit ......... ................. 28-29 I da Bickle F ac ing T he .!'ol"ew Hori zo n .......... .... 29-30 M argaret Hardin Must Ameri ca Go M etric ? ....... ..... 32-3 3 H arland Manchester M ee t Mr. Pepper ....................... .. ....... 34 D r. H . C. Thulin e Quiz :f¢ 7 a nd Answers to Quiz ::±6 .. .. ............................... ....... 35 UTAH NURSE REPORTERS · D istric t N o. 1 ....... ....... ............ Fay Fahske Dist rict No. 2 ..... .............. . K it ty Milligan District ~ o. 3 ...................... Beve rly Ho yt District No. 4 ....... ........ .... ... ..Ann S wase;• Dist ri ct N o. 5 ...... ...... Clara Jean M eyers D istri ct ~ o. 6 ........ ....... ... .... ..lleta N orris 3 Community Health Nursing, Destination - Freeway or Detour tional advancement of nurses, and promote the welfare of nurses to the end that all people may have better nursing care. These purposes shall be unrestricted by considerations of nationality, race, creed, color, or sex.'' In 1966 when the A A's Biennial convention came to an end in San Francisco, the long-sought structure opened the door for increased emphasis on nursing practice. The new structure provides for broad clinical interest diYisions designed to improve nursing practice and the practitioner, regardless of her specific occupational identity. The occupational forms have been established to permit exchange of meaningful information when occupational identity is important. ( Presentation, Utah Stat e Nurses Annual Convention May 16, 1969) ( Doris Wagner) Madam Chairman, members of the Gtah State Nurses' Association and members of the Community Health Nursing Team. First I would like to express my appreciation for being im·ited to attend your convention and then I bring greetings from Edna Brandt, President of the California State Nurses' Association and Director of Public Health Nursing, California State Department of Public Health. the board of CNA and greetings from the Public Health :\Tursing Section. We may be living in the years that will be the most significant in the history of nursing as we think of the issues and changes which have taken place, are taking place, and need to take place. We arc on a freeway that has not been traveled before. We arc keenly aware of the distance yet to go before we reach our destination. The title, "Community Health Nursing, Destination Freeway or Detour" does imply that we arc moving. Samuel Johnson has said, "The use of traveling is to regulate imagination by reality and, instead of thinking how things may be, to sec them as they are." As the official association of nursing, A A has faced the issue that coup led with changing concepts of nursing education, a dramatic shift in emphasis was needed. The top priority of the ANA has been declared as PRACTICE - concerns regarding high standards of nursing practice. In the By-laws of ANA it clearly states that the purposes of the Association shall be to "foster high standards of nursing practice, promote the professional and educa4 To 111ove into this new structure has not been easy - there have been the broader issues: gaining liccnsure ; acquiring greater control over our own educational programs, trying to utilize more effectively other allied hea lth personnel, helping to improve nursing's economic depression, meetin"' new demands of society for nursing service, providing enough and meaning[ ul continuing educational programs and becoming more articula tc to volunteer and speak in behalf of nursing on various local and regional health planning committees. Major social changes such as social protest movements, new in,·cntions, automation, new legislation, new knowledge, new methods of disseminating information all confro.nt individual, organizations, and commun iti es. These kinds of problems and the chronic social changes cannot be settled in a short period of time, but will continually need the attention of the professional organization. In 1966, the House of Delegates did declare that nursing practice shall have first priority among all of ANA's concerns. At the 1968 biennial convention held in Dallas, the first meetings of the five new divisions on practice were held. All five divisions arc drawing up standards of practice and criteria for certification in their respective fields of nursing. In the community H ealth Nursing Division's first meeting you may well remember there was some uneasiness expressed regarding the clinical grouping in this division. Many delegates waited in line behind the microphone to express openly their concern as to who would be included in this division of practice. Doris Since that time there has been continued expression directed to the division by phone, letters, and representative groups asking for clarification as to who would qualify to be a member of the division on community health nursing practice. At the first meeting of the newly elected executive committee held last September, we spent considerable time reviewing the definition of Community Health Nursing as written by the former executive committee in 1967 and reviewed the goals as stated by the committee. The former committee had done an excellent job in trying to synthesize activity of several of the sections into the goals and objectives of the broad field of community health nursing. Emphasis was changed from where you were employed to the broader area of practice. The major problem facing the newly elected executive committee was the identification of who was included in this division of practice. The principle of the broad spectrum of workers in community health is sound but to define it proved to be difficult. In the present goals of this division, the practitioner of community health was suggested as being public health nurses, school nurses, and occupational health nurses. This did leave out a large number of nurses who arc practicing within the broader scope of community health nursing such as office nurses, outpatient nurses, and mental health nurses. Could one identify the occupational group who should belong to this Division of Practice? In a joint meeting of the three ··nmissions (Education, Scr\'ice. and Economic General Welfare with the five division on practice (Maternal and Child Health Nursing, Medical-Surgical Nursing, Psychiatric and Mental Health Nursing. Geriatric Nursing and Communit) Health Nursing) each gave a report of the progress made in this group. It came through loud and clear that there is a commonality among all division of practice and each division views part of their responsibility and activities within the community. In fact, listening to some of the reports, I thought th ey were defining community health nursing practice. When you fill out your membership application forms for A A, you arc instructed to select two divisions of practice. You may be in terested to know that the first time the selection of division of practice appeared on Utah Nurse W~ the applicatio 62,000 nurses vision of Pra checked w1 nursing pract! half the nurn medical-surgic a nurse decici of practice sh the major int dividua] nurs1 think that all division withi; plus communi At the exec ing held in A it was impera the definition nursing. The fl a broad base · area of practi< to note how q munity health on. Now it st review the defi fications could tion that was p tivc committee was as follows "Community ticc is a fie! for which t~ knowledge a arc applied· i needs of co~ dividuals and ma] environ home, the sci work. It is aI1 lies primaril1 peu tic ins ti tu The new reel for Commur practice is as ''Community ticc is a syntr ticc and pu applied to pre ing the health nature of thi and compreh limited to a p nostic group rather than nant responsi health nursing as a whole. T rcctcd to in becomes a v community h ticc only as i lo and contri the populatio We arc wanti the country to l Summer, 1969 Doris Wagner speaks ... e has been ected to the s, and reprefor clarificaqualify to be non commu:tice. of the newly ittee held last considerable definition of rsing as writecutive comreviewed the immittee. The done an exto synthesize the sections ectives of the iunity health changed from 1loyed to the :e. The major newly elected ras the identicluded in this ie principle of )f workers in sound but to · difficult. In is division, the nunity health · public health and occupafhis did leave )f nurses who 1 the broader ealth nursing es, outpatient health nurses. e occupational ielong to this of the three tion, Service. era! W elf arc) in on practice Health N ursN ursing, PsyIealth Nursing, 1d Community each gave a s made in this •ugh loud and a commonality 1f practice and art of their reties within the stcning to some ught they were health nursing r your members for ANA, you ct two divisions be interested to me the selection e appeared on Utah Nurse the application forms, approximately 62.000 nurses did not check any Dirision of Practice. Medical-surgical checked with community health nursing practice next with less than half the number that had checked medical-surgical nursing. How does a nurse decide which two divisions of practice she will check? What are the major interest areas for the indil'idual nurse? It is reasonable to think that all nurses will check the dil'ision within which they practice plus community health nursing? At the executive committee meetheld in April, the members felt it was imperative to again look at the definition of community health nursing. The first definition provided a broad base to help identify this ·area of practice and it is interesting to note how quickly the term "community health nursing" has caught 1m. Now it seemed appropriate to reriew the definition and see if clari fications could be made. The definition that was published by the executire committee in December of 1967 11a as follows: in~ "Community health m1rsing practice is a field of nursing practice for which there exists a body of knowledge and related skills that arc applied · in meeting the health needs of communities and of in dil'iduals and families in their normal environments such as the home, the school, and the place of work. It is an area of practice that lirs primarily outside the therapeutic institution." The new recommended definition for Community Health Nursing practice is as follows: "Community health nursing practice is a synthesis of nursing practice and public health practice applied to promoting and preserving- the health of populations. The nature of this practice is general and comprehensive, rather than limited to a particular age or diagnostic group; it is continuing rather than episodic. The dominant responsibility of community health nursing is to the population as a whole. Therefore, nursing directed to individuals or groups becomes a valid component of community health nursing practice only as it intrinsically relates to and contributes to the care of the population as a whole." \\'r arc wanting nurses throughout 1r country to look at this definition Summer, 1969 and see if this more aptly describes the practice of community health nursing. To function effectively as a community health nursing practitioner one needs a knowledge of both nursing and public health. No longer is the focus on just one individual, but on the community - the population as a whole. If you are really looking at the entire community, the focus cannot be on just a particular age group. There is need of continuity of care from birth until death nursing service over a life continuum. I would like to deviate for just a moment and have you look with me how modern medicine and standards of living have evidently been able to do a great deal for the young, especially the very young, but not so much for the old. There has been a dramatic increase in health and life expectancy during the 20th century, but this has been primarily as a result of developments which affected the younger age groups. ·'The expectancy of life at birth in the United States has increased from 4-7.'.l years at the turn of the century to 70.5 years in 1967, or by well over 20 years. The number of expected years of life remaining at age 5 has increased by about 12 years. and that at age 25 about 9 years, but at age 65 not even 3 years." 1 As we look at these figures we need to ask if certain age groups have been neglected. If nursing within the community is to be effective, it is essential and inherent that all age groups be included as the entire community is considered. As the professional organization has changed so the members are confronted with change. It is important that we learn how to respond appropriately to change within the new environments which are created daily. As individual members I think it is important that we do not limit our vision or restrict our practice by labels. The simple identity of professionals has become a complex. It would be interesting to take time and make a list of all of the new workers in the health field which have been added during the past ten years. A nurse is no longer just a nurse. I remember well as a child if a person asked me what I wanted to be I just spoke up and said, ·'a nurse." Never once did it enter my mind that I would come to a crossroad when I had to decide what kind of a nurse, in what kind of setting, and what additional pre- paration would be needed. I couldn't wait until my 18th birthday so I could enroll in a School of Nursing. The crossroads - or should I say detours and barriers came very quickly. As a new graduate from a diploma school, a supervisor on a medical service, I realized all too quickly that I was not prepared to do the kind of nursing that was being ·e xpected of me. Requirements changed - first it was a degree, then a special kind of a certificate, then it was another degree. What seemed adequate at one time was no longer adequate. Though the freeways and expressways to obtain nursing education are still under construction. the detours are slowly being eliminated and the profession is moving ahead. I am convinced that with the spiraling cost of hospitalization and medical care, more health care will be done within our communities. l~dna Brandt, prl'sident of CNA has continually H' -e111 phasized that we nnd to look at the chanies in delivny of lu,alth care srrvices and real!')' look at where arc the patients that need the care. Will we as nurses be prepared to meet the needs of increased hmlth care within the com111unit~1? I was amused when I looked up some of the words in the title of this presentation in my 1956 Webster New Collegiate Dictionary, for the word "freeway" was not listed. Diel we not have freeways in 1956? I am sure we did, but they were not as common. Now we are concerned not only with freeways, but with expressways, turnpikes, superhighways and thruways. All methods devised in order to reach a destination with less confusion and hopefully in less time. We can compare reaching our destination with traveling. As nurses we arc all aiming for a common goal - improved nursing practice that all people may have safe nursing care. Destination: a community with improved organization and delivery of health services whereby an individual can receive safe nursing care. The first thing we will do is study the map to determine where we arc going. We note that social changes have affected our decision as to the road we will take, the rate which we travel and the cost of the trip. Students graduating this year have been part of four years of major health legislation in the United States 5 "What ii "A real emphasis on Nursing Practice" legislation that has directly affected health care and nursing practice. I am thinking primarily of Medicare, Medicaid, Comprehensive Health Planning (89-749) and Regional Medical Planning (89-239). The second thing we do is review our preparation for the trip. When will it be necessary to refuel on our trip. Can we reach our present destination with the present equipment-education? The third item we need to determine is the road we will take - are we equipped to travel the freeway? A freeway is defined as a multiplclane highway designed to move traffic along smoothly and quickly, as by the use of interchanges. As we enter the freeway we arc made aware of the various models of cars, the various sizes, shapes, and colors - all moving along in one direction. Occasionally there will be an auto or some vehicle which you feel has caused a slowdown in the traffic - the car that weaves in and out and may cause an accident the car that is stalled with the hood raised indicating a need for help. It is easy to parallel traveling on a freeway with many and varied types of workers in the health field, all on the same road with the same intent of providing health care services within the community. Community health nursing has entered on the freeway. There will be detours and unexpected exits but we will move ahead at great speed. REACHING OUR DESTINATION WITHIN THE ORGANIZATIONAL STRUCTURE The ANA is assuming the responsibility for defining and realizing goals for nursing education and practice which will provide quality and quantity nursing care for all the people. Presently ANA is in the process of developing guidelines and standards for selection, education, utilization, supervision, economic reward and working conditions of nurses and all personnel who support the services of the profession. In the new structure of the ANA, Community Health is designed as one of the five major divisions. Within each division of practice there is the executive committee which is elected. They in turn appoint two important committees: The Committee on Standards and the Committee on Certification. Both of these committees are working hard in establishing standards of practice whereby recommendation for certification of the skilled practitioner can be made. The func6 tions of the Committees are: Committee on Standards: 1. Develop standards 2. Devise methods to gain acceptance and implementation Committee on Certification: 1. Develop specialized criteria 2. Review credentials of those applying 3. Certify division members who meet special criteria 4. Endorse certified practitioners for appointment as fellows in the academy. In the past we have always talked about the Functions, Standards and Qualifications of a specific occupational group. If you will carefully look at those reports you will note that functions, not standards, arc given. It is my opinion that this new structure will assist us in identifying the standards of practice and help clarify to other disciplines what can he expected of nurses in the \·arious practice areas. It will help identify ways for better utilization of pcrson1wl as well as the evaluation of the practitioner. This di,·ision can then 1110\T tu take 111on· action. This division can help put the organization into focus. The new structure pro,·iclcs for the assistance of State ::\T11rses Associations from the Nation;1 J le\'l·I · to become im·oked in grassroot act1nty to help State Associations achieve their goals. The national organization provides: Manpower. knowledge, funds to augment programs within each state. It is up to the State Nurses Association to identify their own needs and become involved in grassroot activities. I cannot over emphasize the importance of determining the nursing needs within a specific state and within a certain district. It was of interest to learn of the Commission to Study Nursing in Utah. I would like to share with you what has happened in California in one of our local districts .A group of nurses in the Sacramento community felt that the local district association was not really meeting their need. The sections were poorly attended and the programs not too meaningful. A group of young, active, and "alive" nurses took it upon themselves to organize a group that would be active and would bring together nurses to discuss common problems and needs and share mean ingful information. Thus on a local level they organized a community health nursing group - this included any nurse interested. Those attendin~ came from various occupational health groups i n c 1 u d i I) g school nurses, office nurses, public health nurses, etc. This group was highh motivated and moved ahead. They planned good programs, helped in· crease membership within their local district and led the way to revitaliza· tion within their professional group. At the California State Nurses Con· yention held in February, it was thi< newly organized group th<,it domi· nated the Public Health Nursing sec· tion, sharing their success in settint up a division of practice that in. eluded all "specialist" interested in nursing with in the community. Thi' State Association did not elect at thi1 time to move into divisions of prac· tice, but to retain sections and 01" ganize a Council of Nursing Practict ThC' State Association plan is to con· centrate working on structure clurint this biennium . This Council ol ::\! ursing Practice wi II be made up of the chairmen of the various confer. encc groups. At the convention six confcn·ncC' groups were organim and officl'rs elected. The six confer· ence groups include: Communit, Health Nursing, Medical-Surgica Nursing, Geriatric Nursing, Materna and Child Health Nursing, Psychi· atric and Mental Health NursinQ. and Directors of Nursing Practin An effort is now being made to t · tablish conference groups in the \'al· ious local districts. How this will h done is up to the membership. On of the questions raised is, what the1 will be the function of the sectiom. Sections plan to work closely wit! the community health nursing con· fcrencc groups. Historically section have been involved in structure, o\ ganizational policies, functions , cco nornic programs, job qualification' etc. - with very' little or no en phasis on practice. At the first mett ing which is scheduled for June. 1 is planned to expore how oth1 groups may join the council of nrn"· ing practice. For example, if th school nurses feel they would like tr have their own conference group..I committee has already been set 11 whereby a two day meeting will I held next March sponsored by ti council of nursing practice. Onr d.i is designated at present to be spe1 on clinical practice - a real en phasis on nursing practice. It is ttr early to predict how this will " evolve but much enthusiasm h, hcen generated towards the clevelo1 ment of programs emphasizing clirn cal practice. Utah Num Some nur their identit others do nc involved in nursing prac arc going tc differently prehensive convinced d till think setting. It is note standing an munity he among merr large numbe munity He namely oc• school nurse health adm instances re sional healtl tional settir school heal· heal th nursi other spccia zations such :\" urses and tion of lnd tural to hav1 with a stru< cupational : important t ognizcd wit! On the I< to have a s fessional or monalities o ily in the c. structure wl health neec Under the : develop on fluid enoug various occ1 communicat enough to ment chang be effective practice wit problem-soh he used, the on a local developed a out a progr: meet the sp licvc there present 01 which will e effective de and increase REACHING ( Co NL There is systems of ci IN Summer , 196 "What is our destination?" 'hose attending occupational d i I} g school public health pp was highly 1 ahead. They s, helped inthin their local ~y to revitaliza·essional group. te Nurses Conary, it was this up th<,tt domith Nursing sccccess in setting acticc that in" interested in :immunity. The not elect at this ,·isions of prac~ ctions and orursing Practice. 1 plan is to con1tructurc during is Council of be made up of various confcrconvention six NCIT organized The six conferc: Community iicdical-Su rgica'l irsing, Maternal forsing, Psychiicalth Nursing. ursing Practice. .ng made to csoups in the varIow this will b<' embcrship. One ~ cl is, what then of the sections ;i irk closely with th nursing con:orically sections in structure, oY' functions, ecob qualifications. ittle or no ern.t the first mectled for Junc, it ore how other council of nursexample, if tlH' ey would like to crence group. A ~dy been set up meeting will h<' ponsorcd by th(' ractice. One da~ sent to be spent a real emractice. It is too iw this will all enthusiasm has 1rds the dcvclopmphasizi ng cliniUtah Nurse Some nurses are reluctant to lose their identity of their specialty and others do not really want to become involved in the broader scope of nursing practice. I believe that nurses arc going to have to learn to think differently - we talk about comprehensive health care, but I am convinced that the majority of nurses still think of a patient in a given setting. It is not easy to develop an understanding and a philosophy of community health nursing practice among members of the Division. A large number of constituents in Community Health Nursing Practice. namely occupational nurses and school nurses, are employed by 11011health administrators and in some instances represent a single professional -health voice in their occupational setting. Nurses employed in 1chool health and in occupational health nursing positions have ties to other specialized professional organi1ations such as the Council of School \'urses and the American Association of lndustrial Nurses. It is natural to have this kind of relationship ll'ith a structure related to your occupational setting. Yet it is vitally important that their needs be recognized with the ANA structure. On the local level it is important to have a structure within the professional organization where commonalities of working with the family in the community are shared. A structure where nurses look at the health needs of the community. Under the new ANA structure you develop on a local level needs to be fluid enough to provide for free rarious occupational nurses, strong communication and exchange among enough to recommend and implement change, and sound enough to be effective in improving nursing practice within the community. The problem-solving technique needs to be used, the major nursing problems on a local level identified, a plan dcl'elopcd and implemented to carry out a program to effect change and meet the specific needs. I firmly beliere there will be improvement of present organizational structures ll'hich will enhance and permit more effective delivery of health services and increase productivity. REACHING OUR DESTINATION WITH IN COMMUNITY HEALTH NURSING PRACTICE There is a need to develop new systems of delivery of health services Summer, 1969 which will translate into reality each citizen's right to quality services, especially th i s society's dis-advantages groups. What will our commitment and attitude be regarding reaching out to the various dimensions of health care? In community health nursing we need to understand the relatedness of social, cultural, and environmental factors as they affect people's health. We need to understand that certain factors in the community are important for the health and well-being of individuals. Therefore, we need to learn and understand the community in which we work. Ticm COMMUNITY As we arc traveling on the freeway, is our destination a community where excellent health care is provided? The first thing we need to do is assess the community to idcntify some of th<' factors which affect the health of the population. I have often paralleled the assessment of a community as to a physician assessing thl' needs of a patient. Each Community is different just like each patient is different. First we need to review the history, identify the problems or complaints,, collect the necessary data, do appropriate studies, make a diagnosis, then prescribe treatment and later evaluate the effectiveness of the treatment. In assessing a community it is important to recognize that communities may differ in some of the following ways: l. Geographic conditions and climate 2. Power structure 3. Type of government 4. Emotional patterns 5. Nutritional patterns 6. Community organizations 7. Laws 8. Prides and prejudices 9. Illness and health patterns 10. Available facilities: medical, educational, recreational 11. Certain accomplishments 12. Employment opportunities 13. Type of population, age, educational level, ethnic groups 14. Communication facilities To know the kind of community will help determine the kind of health care services needed. The nurse must broaden this traditional practice of the one-to-one relationship of nurse to patient or patient to clinic, to a concern with neighborhood, community, and government as they relate to and affect the health of individuals. He must thus become involved in the broader aspects of his community laboratory in transportation, housing, land use. ets. - in order to determine what changes in the comprehensive and inter-related social system which make up that community arc needed to create a more favorable climate for preventive health measures. We are on the freeway headed towards what we say is improved health care. But as we are on the freeway we realize that many cars do not dri\·e defensively, but rather slow down traffic thus slowing down progress towards improved and continued safe care. As chairman of a subcommittee of RMP Arca III called " Allied Health Personnel,. concerned primarily in the continuum of health care. I was startled Moving Ahead ... Valley West Hospital 4160 West 3400 South LARGE EN OUGH FO R SERVICE - SMALL ENOU GH FO R FR IENDLINESS Serving: Granger, Hunter, Magna and Kearns 7 " We need to encourage new ideas" when after the first meeting a nurse who is an insen-ice education director said, "If we are not going to talk about writing a grant to meet my needs for a training program to prepare nurses to work in coronary care units, then I do not have the time to work on such a committee." How many nurses are concerned about the continuum of care about the health needs within and of the community? THE PERSONNEL In the future community health nursing will be vastly different than now. I see the community health worker a very important person. This will be the individual who will assist families in and out of the maze-way of health care facilities. She will be a person skilled in working with many disciplines, she will work with many of the agencies to assist in securing care. The question is raised. will this person be a specialist? A question raised within the Division of Community Health Nursi1w Practice is if community health nur~~ ing is a specialty. From my point of view, it all depends on how we elect to define specialty. Working in a community setting does not mean that one is a specialist in community health. Driving a car on the freeway by no means makes you a specialist in au tomobilc construction and design. In ovember of 1968 a statement on the Public Health Nurse Specialist was given to the public health nursing section of APHA. In their statement, the baccalaureate graduate who elects public health nursing as her area of work becomes a public health nurse specialist through additional academic preparation and practice. In a paper presented at the American Heart Association Clinical Nursing Conference, Dona Gilbo stated that a "nurse earns the title of clinical specialist - or master clinician - because of her continuous intellectual effort in investigating her specialty area, her continuous and broadening experience in the care of patients and her discriminating judgment in determining their nursing care, her ability to communicate her knowledge and enthusiasm to her profession and her responsibility for her own actions." At this time I do not choose to determine if a community health nurse is a specialist or a generalist, but I would like to site an example of how I see community health nurs8 ing practiced. In California, effecti,·e July 1, 1969, AB 1454 (the Lanterman-Petris-Short) will change the method of providing mental health services in all major communities. The Lanterman-Petris-Short Act terminates the old commitment system for most of the mentally ill now subject to commitment and substitutes modern procedures designed to provide prompt help with a minimum of legal disability and stigma - prefcrably on the local level. Needless to say, many questions have risen as to how this will affect the present methods of providing services within the community and will nursing be affected? A study committee was set up in our district to provide an opportunity for nurses concerned and interested with this legislation to meet and study the present laws and bills related to co11111111nity mental health services and to consider the effecti\-cness of local mental health scn·ices. This study committee has brought together nurses employed in hospitals, outpatient departments. <·xtended care facilities, voluntary hralth agencies, schoo ls, industry and go,·errnnental agencies all interested in sharing information and exploring ways in which nursing will be affected by the enactment of this bill. Mental illness is no rcspector of a specific age group, a specific work setting, a specific ethnic group it reaches into the community affecting the young, the aged, the parent, the employer. Nurses employed in various occupational settings will be involved. For nurses to effectively assist in the implementation of this Act, they need to know their community, the resources and then take the initiative to work closely with other nurses and mem bers of the health team concerned with the care and treatment of the individual patient and his family. At this time we need to encourage new ideas and experimental programs to provide effective alternatives to existing methods of health care. The community health nurse may function most effectively if she is attached to a group practice clinic. A nurse assigned or employed by a group of physicians who will assist with the many screening procedures, educational and preventable procedures and will make visits into the community to sec the family or a member of the family. If there is an agency who could better meet the needs of the individual or family, then the patient would be referred to that agency. In the East there is one g roup practice clinic where nurses "Many a are employed as co-partners in prac tice. They are paid on a commissio basis. In this particular instance th one nurse is highly skilled in mater nal -child health and the other nur is skilled in obstetrics. In a few places we have a nur employed by a hospital who war~ out into the community. She viewed as extending the services o the hospital into the community. foresee there will be more brid~n of the gap between the hospital an the community. I project that u smaller communities the hospit, may become the comprehensi1 health center with extension into th community, permitting a free en trance and exit for patients in th ,·arious levels of needed care. Ther is an increased need to help th patient move in and out at the rm ious Je,·els of care. The goal is keep ing the patient functional. The pa tirnt will be in an institution for tr minal care, acute care and skill~ nursing care. This same treatmen can be gi,-en at appropriate peril)( in a residential setting. I fon·1r morC' family health centers. If 11 would have the fami ly health centt. then many of the special ccntt. could be incorporated with that kin of center. Recently we did a health sum of a section of our county wher there is predominantly all new h9U' ing, the average income is aroun $10,000 per year and though healt care is available it is not necessaril sought out or used. I foresee th, especially in some of our large su~ urban areas we wi ll have more grou practice and classes, attracting individuals to discuss health problellll having available mu lti-phasic screen ing programs and providing som minor treatment. In the lower ir come areas, especially in our lar( cities, there will be more utilizati of the health care centers whic really is nothing new - but th utilization will be different. Withi the home, nursing care of varyin degrees will be needed. There will ~ needs at times for the "clinical spr cialist" but it will be the generalist who does counseling, coordinatin. treatments and giving of nursin care. The reason for generalist - th individual has more confidence in person than in a group. Regardli of how effective the group may ~ the individual looks to some on person with whom they may identif1 Who best can fill this position but community health nurse? Utah Num In one oJ the Bay Are: is that the will be retu tion's 20th - The Arn Practice offer certific It is not < the number It would 1 munity heal generalist re a nurse is a borhood or sponsible for is the perso care needed individual t treatment, o pital for c nurse from department nity health could not g1 functions of official heal she could nc guage too ' seemed to bf with so man· attached to i preferred hf community She was a though this was the or give care a: tants. She vided prena did the ma infants and 1 education cl tions and so treatment. J center once ords and Sll major healt kind of heal munities ? If our d proved heal munity it is ognize the ' health team aid e, th ere i there is need person w h o sponsibility c In the de vices we wi method s ev• method ther involvemen t policymakin, Summer, 196 "Many and varied ways of delivering Health Care" ~artners in pracn a commission Jar instance the killed in materthe other nurse cs. ve have a nurse ital who works munity. She is r the services of e community. I e more bridging the hospital and project that in ~s the hospital comprehensive xtension into the ting a free enpatients in the ~ ded care. There eel to help the :I out at the varlhe goal is keepctional. The pa~stitution for tercare and skilled same treatment propriate periods :tting. I foresee I centers. Ir \\(' ily health centers special centers eel with that kind a health survey county where 1tly all new h9us1comc is around :id though health is not necessarily :l. I foresee that of our large subhave more group ~s, attracting inhealth problems. .ilti-phasic screenproviding some [n the lower inally in our large : more utilization ·e centers which new but the different. Within care of varying led. There will be the "clinical spebe the generalist'' .ng, coordinating. iving of nursing ir generalist the ·e confidence in a group. Regardless ne group may be. ~ ks to some one they may identify. this position but a nurse? Utah Nurse In one of the medical schools in the Bay Area, the projection by some is that the "General practitioner" will be returning. Presently the nation's 20th primary specialty group - The American Board of Family Practice - is busily preparing to offer certification examinations. It is not clear if this will increase the number of general practitioners. It would be possible that the community health nurse might play the generalist role. In several countries a nurse is assigned a specific neighborhood or community and is responsible for all health problems. She is the person who either gives the care needed, directs the family or individual to a health center for treatment, or refers them to the hospital for care. Last December a nurse from Thailand came to our department to see how the community health nurse functioned. She could not get over how limited the functions of the nurse working in an official health agency was. Though she could not speak the English language too well, the biggest barrier seemed to be in describing a program with so many policies and regulations attached to it. She explained how she preferred her system - having one community she was responsible for. She was available day or night though this did not mean that she was the only person available to give care as she had several assistants. She did the deliveries, provided prenatal and postpartal care, did the major health screening of infants and children, provided health education classes, did all immunizations and some minor diagnosis and treatment. A physician came to the center once a month, reviewed records and saw any individuals with major health problems. Would this kind of health care fit into our communities? If our destination is truly improved health care within the community it is important that we recognize the various members of the health team. There is a place for the aide, there is need for the specialist, there is need for the "middle trained" person who will have the greater responsibility of health care. of service including evaluation of services. Mr. Dave Williams of the California Council of Labor Unions for Health Plan Alternatives at a Health Symposium said that the labor union is seeking to strengthen the voice of the patient in the nonmedical decisions affecting his health and welfare - in the legislative halls - across the table with the providers of health services - in the planning sessions - all to the end of broader, stronger, more comprehensive health care. In this era of a fast way of living, driving, and doing, we need to act fast. We need to strengthen our methods and involve more citizens in the planning and implementing of our programs. I have always wondered why in official health departments and some other health agencies we do not have an advisory board of community health nursing. With accreditation of health agencies by NLN, advisory boards are required. There are still too few groups responsible for nursing care who do not use citizens in the planning and implementing of their programs. As we plan for the delivery of health services, new patterns for supervision and administration will need to be developed. The question has been raised as to the function of the administrator or the supervisor. At the ANA Convention in Dallas one of the debates was on this very topic: "Directors of nursing services need not be nurses." The question we need to answer is how can we most effectively and efficiently give direction and guidance to assure quality services? ~ ...t-N U R y Summer, 1969 FAMILY CARE V\ G .ll.1l J{)l/'~ VS AT THE PRlMARY c:HJLDRE/l/'5 HO SP /TAL f fl.} ::J CcuN1BING TOWARD PROF ES'S IONAL EXC I:: LLfNC E iN NURSJN& N \II' 111'17 In community health nursing we need to identify where we are going, the method to be used and then determine the effectiveness. The structure of our professional organization provides room for new innovative ideas for nursing practice. Our citizens are asking to be involved in planning health care and most significant, the patient is speaking out to let us know if the service or health care is meeting the needs. We in community health nursing need to be aware of some of the trends and health problems which will directly affect nursing. Some of the trends and health problems are as follows: The battered child The neglected adult Increased birth defects Hazards of pregnancy - continued importance of prenatal and postnatal care exc ELLE NT ~~L~" ~..>- D ~~~ The Method In the delivery of health care services we will see many and varied methods evolving. In planning the method there needs to be more active involvement of the consumer in both policymaking, planning and delivery C H Conclusion Traveling on a freeway can be exhausting and exasperating. It also can be enjoyable, rewarding, and satisfying. Can providing health care within the community be effective if we are traveling at such a fast rate of speed? Will we reach our destination knowing that the individual members of the community are receiving quality health services? The patient does not want the assembly-line method of care - there is a real advantage if the care can be provided within the community, within the patient's own home. This is the patient's territory and the patient is in a position to actively remove some of the barriers to care in this setting. 1JU. ~ 9 "Nursing is not standing still" Health problems resulting from poYerty and or ignorance Disabilities from car accidents Ylisuse and abuse of medication and drugs Food. water. and air pollution Sight and hearing hazards Malnutrition - nutritional deficiencies and food habits Increased teenage pregnancy Increased suicides I gnorance and misconception regarding health and de\·iations from health All types of morbidity (increase in arthritis, heart disease ) Communicable diseases Oli\·cr Wendell Holm es said. "l find the great thing in this \\'Oriel is not so much \\·here we stand, as in in the field of community health 11·hat. direction \\'C arc movinCY. " '"'(' ~ nursmg arc not standing still, wl' ar(' on the frcc1,·ay and we arl' lllovino-. There haYc been detours and the;~ 11·ill continue to be detours. but I am confident that as a profession we can meet these and move a head. A balance in health care can be provided if \l'C accept the challenge for change. Then knowledge coupled with integrity, love, honesty, and faith will assist us to assume our role within the community to achicw the goal of providing all people with sa fe nursing care. " If man does not keep step with hi s companion Perhaps it is because he hears a different drummer. Let him step to the music which he hears However measured or far away." Presented in part by Doris L. Wagner Secretary, Executive Committee ANA Division on Community Health Nursing Practice "A Nurse's Aide in the Head Start Program" For the first time in the Ogden City School Head Start Program, a nurse's aide has become a member of the Head Start team! In a brief orientation period the nurse's aide learns the techniques of v1s10n screening, assisting nurses in immunization programs, measuring and recording heights and weights, also the aide gains an understanding of the importance of a complete physical examination, immunizations, tuberculin testing, and preventive dental care for pre-school children. When parents, are reluctant to make appointments with the doctors and dentists, the nurse's aide encourages the mother and together they make an a appointment. Often this is the first time the parent has made an appointment and taken a well child to a doctor's office. The nurse's aide offers transportation and moral support by going with the mother. An objective of the Head Start Program is to try to effect changes, or, to help people make their own changes . (One mother indicated next time, she would not be afraid to go alone to the doctor's office. ) Parents are encouraged to follo11 through with dental appointments for their children enrolled in the Head Start Program. Many appointments are broken or missed. The nurse's aide has tried to encourage these people to keep the dental care. appointments offering transportation and support. Several parents expressed interest in preventive dental care for other members of the family. The school nurses agree the nurse's aide helped make attendance and follow up visits to medical and dental clinics more successful this year. - Elma Humphreys, Supervisor of Ogden City School Nurses, Dept. of Pupil Personnel, Ogden Board of Education. NOTICE Public Health Nurses School Nurses Community Nurses U.S.N.A. U.E.A. SESSION BIBLIOGRAPHY Kelly, Cynthia H ., " Detroit -Since Last ?ummer," American Journal of Nursing, June, 1968, pg. 1278-1982. Minckley, Barbara Blake, "Space and Place in Patient Care," American Journal of Nursing, March, 1968 pg. 510-516. ' .................... A Blueprint to Bui ld On, A report to members, 1966-68. .................... ANA Convention, A Week of '.'Firsts," American Journal of Nursing, June, 1968, pg. 1267. Schutt, Barbara C., "Converging on Clini cal Practice," American Journal of Nursing, March 1968, pg. 497. .................... Toward a Social Report, U.S . Department of Health, Education, and Welfare. January 1969, pg. 2. ...... .. ............ "Plann ing for Change," Monographs in the Professional Nurses Executive Library, Leadership Resources. Inc., 1966, pg. 1-18. Eleanor Hawley - Life Education" SALT PALACE Plan to attend Utah Nurse - - - Most of w thing that h1 stopped, the know ,-cry Ii Henrv K. B1 esthe~ia resea School, one , research scie1 that pain is each man i1 for himself. Not only i: it defies uni· is interpretec sional and c The biologis sory signal tr when harmh jury. The phi ·'a passion of process and an attitude ti theological < strong moral To the so threat of it learning and To the psych pain as anot individual ar est to the p~ sible psychog a research s< sponse to a s manner of in ditions. To 1 message to b and acted u1 Lion of a pa the death of stance, the p< dix, were to · intestinal pai .~iven a laxa· Certain ty] creel diseases clescri bed sue a patient wh of occasional in a particul Upon examir there seemed reason for th' only became OCTOBER 10, 1969 Mark your Calendar - "There is ('asy to bear geon Rene 1 pain of other The physic of the pain ; cate it by ct cause cannot alleviate the a tolerable dE not always w "Nurses Role In Family 10 ~------------~ ------ Speaker Pain Summer, 1969 of the Head try to effect people make One mother e would not .o the doctor's ged to follow appointments trolled in the Vfany appointmissed. The to encourage ne dental care. g transportaeveral parents 1reventive denembers of the irses agree the ake attendance o medical and successful this ;, Supervisor of ·urses, Dept. of den Board of .. Nurses ·ses lurses .E.A. N Pain • • • 'There is only one pain that is ·asy to bear," said the French sur~eon Rene Leriche, "and that is the pain of others." ~1ost of us think of pain as something that hurts and the quicker it is 'topped. the better. Beyond that, we know ,·ery little about it. Even Dr. Henry K. Beecher, professor of an1·sthesia research at Harvard Medical School, one of the nation's foremost esearch scientists on pain, concludes that pain is indefinable except as each man introspectively defines it for himself. \lot only is pain so subjective that it defies universal definition, but it is interpreted from different profes1ional and cultural points of view. The biologist considers pain a sensory signal that warns the individual when harmful stimulus threatens injury. The philosopher has called pain ..a passion of the soul," an emotional process and a moralizing influence, an attitude that closely resembels the theological concept of pain as a strong moral force. To the sociologist, pain and the threat of it are powerful tools of learning and of social preservation. To the psychologist is concerned with pain as another form of perception, indil'idual and modifiable. Of interest to the psychiatrist and the possible psychogenic aspects of pain. To a research scientist it is a total response to a stimulus modified by all manner of internal and external conditions. To the physician pain is a message to be decoded, interpreted, and acted upon. The misinterpretation of a pain message could mean the death of the patient - if, for instance, the pains of rupturing appendix. were to be mistaken for griping, intestinal pains and the patient were given a laxative. The physician diagnoses the cause of the pain and then tries to eradicate it by curing the cause. If the cause cannot be cured, he tries to alleriatc the pain and reduce it . to a tolerable degree, but unfortunately, not always with success. Certain types of pain arc considerecl diseases in themselves. Leriche described such pain in his account of a patient who, at first, complained of occasional attacks of severe pain m a particular location in his jaw. Cpon examination of the jaw itself, there seemed to be no indentifiable reason for the pain. The attacks not only became more frequent, but, in- nd Utah Nurse Summer, 1969 U.S. Dept. of Health , Education and Welfare National Institutes of H ealth stead of being localized. the pain spread over the man's face. His entire life became dominated by the neuralgic pain and the fear of it. The slightest movement of his lips. a twitch of a facial muscle was enough to provoke an excruciating attack. Alternating between dread and pain. he dared not brush his teeth or shave, even feared to speak and gradually withwdrew from professional and family life. Utterly debased by pain and fear, he spent his clays and nights in despair like an entrapped animal. That combination of symptoms recurring pain, unpredictably set off, and its almost unbearable intensity - is the classical pattern of tic douloureux or trigeminal neuraligia. Leriche strongly disputed the concept that pain is a necessary warning signal for man's preservation. Pain, he believed, is a disease in itself that, while it may provide heroic examples of fortitude to others, dehumanizes like madness. What purpose does the pain of cancer, neuralgia, arthritis serve? As a warning, the pain is too late, for by the time pain is perceived, the disease is well advanced. And what of those insidious diseases that are not accompanied by pain, like diabetes? It is only modern times that the value of pain as a signal and a warning could be responded to therapeutically on a broad scale, for only recently have modern diagnostic and surgical procedures and drug therapy given physicians reliable means for curing disease or repairing injury that caused that pain, or for controlling certain types of persistent pain. It is commonly believed that if man did not feel pain, he couldn't survive. The child learns very early to avoid fire because of the pain of burns. Yet, some people who are born without any sensitivity whatsoever to pain manage to survive. The twentieth century parent trains his children to avoid being hit by cars without the actual experience of an accident to teach them. The two concepts -- that pain is a necessary warning signal for the body's protection and that it is in itself a disease - arc reconcil ed by Dr. John J. Ronica, author of the definitive textbook for physicians, ·'The Management of Pain," who says that pain can be one or the other at different times and in the same person. In certain initial stages, like stimulating the hand to pull away from a sharp object, pain serves a useful purpose. But in its intractable, debasing stages, serving no purpose, it becomes a destructive disease. Man's need to explain himself and what happens to him has, through the ages, produced a variety of reasons to account for pain. In his primitive stage, man attributed pain to capricious spirits which enter his body and maliciously tourment him, spirits he tried to humor and placate with elaborate rituals and sacrifices and which he tried to keep away from him by taboos. Among primitive peoples these beliefs still prevail. The belief in malicious spirits gradually gave way during medieval times to the belief that, whatever ill fortune, including pain, befell a man, he fully deserved, miserable sinner that he was. If an occasional man considered himself to be at heart just and good, it was appropriate for him to accept pain and other afflictions as divine tests of his faith and fortitude. Underlying either attitude was the conviction that suffering on earth was Man's destiny, but after death, his lot must surely take a turn for the better. Man's ability to rationalize suffering has been in itself a sort of analgesic that helped him to adjust to pain. His various explanations have served him well, for, until quite recently, there was little he could do to cure or mitigate pain. THE PERCEPTION OF PAIN There are two general types of pain: skin pain that makes us act quickly to escape the continuing stimulus of pain; and deep, lingering aching that tends to make us withdraw into seclusion and inactivity. Besides these general types are particular ones like itching, a form of pain that can torment almost intolerably, even to the point of selfmutilation and scarring. The itching of chickenpox can now be controlled by a drug ,thereby cutting down on the scars children cause by their frenzied scratching. Another type of pain, so strange that it induces disbelief and sometimes even scoffing is the "phantom limb" that itches on the sole of the foot that isn't there. Those who have had an arm or leg amputated may suffer almost intolerable itching or acute pain in the " phantom limb. " So real in fact is this type of sensation that some patients have killed themselves to escape it. Pain intensity can range from excruciating neuralgia to almost no pain at all with wide degrees of pain with particular types of injuries like 11 Pain . . . pain present: dose is incre< sion of the hi becomes de struggles as ~ efforts to esc pain. She no the obstetrici 1 hcrent. BYU NURSING PROFESSIONAL NURSING TECHNICAL NURSING EDUCATION EDUCATION COLLEGE OF NURSING COLLEGE OF INDUSTRIAL AND TECHNICAL EDUCATION BACCALAUREATE DEGREE ASSOCIATE DEGREE Elaine Murphy, Dean E. C. Jeppsen, Dean Ann Bruton, Director Brigham Young University 2240 Smith Family Living Center Provo, Utah Telephone: [phone] , Ext. 2641 L.D.S. Health Service Center 12th Avenue and E Street Salt Lake City, Utah Telephone: [phone] , Ext. 2404 Pain ... cuts, puncture wounds, and abrasions, from a sharp, brief sting to prolonged, intense throbbing. Certain parts of the body are more sensitive to pain than others, the eye, for one. An almost invisible particle striking the eye causes instant pain which may be intensified by the fear of damage to the eye. In man's long experience in the use of pain to punish his fellowmen or to make them change their opinions, he has become very sophisticated about methods of torture and the parts of the body most sensitive to certain methods and instruments, even to the precise timing most likely to produce the desired result. Superficial wounds are more painful than deep ones. Bullet wounds, for instance, are generally painless. Pain that arises inside the body is quite different in quality from that experienced through the sense organs in the skin. Within the body, the solid organs like the kidney and liver arc insentitive. The hollow, tubular organs, the ureter, bladder, stomach, intestines and blood vessels, and the supporting tissues and membranes, though ex q u i s i t e 1y sensitive to stretching or distortion, especially when inflamed, do not respond painfully to other types of stimuli. The spasms caused by kidney stone colic, 12 ~~~~~~~~~--- I for instance, are considered one of the most excruciating types of pain. Muscles, though they do not have the pain sensory organs of the skin, can cause severe, crippling pain when the products of muscular activity are not removed fast enough by the blood stream because of some circulatory problem. Angina pectoris is a type of muscular pain that arises in the heart muscle, particularly after exertion. A rather common type of pain in people with poor circulation in their legs is called intermittent claudication, a pain which knots the leg muscles after physical activity like walking. In a medical history, a physician might describe his patient's affliction as a " three block claudication," the block length, of course, related to local measurements. PSYCHOLOGICAL ASPECTS The psychological nature of pain is so complex as to be almost beyond comprehension. Dr. Howard W. Haggard in his book, "Devils, Drugs, and Doctors," calls pain the supreme subjective phenomenon of disease and says it is almost wholly mental. " A man during rage feels no pain from injury until after his anger has cooled; the same man waiting in the anteroom of the dentist may suffer agony in anticipation. The early Christians, while being burned alive, signaled to their friends who waited for the ordeal, by raising their seared arms in the flames to signify that they felt no pain. Religious enthu· siasm was their anesthetic, as it ha; been for many fanatics who ha11 voluntarily mutilated their bodies.' For the burning martyrs, the pain. despite the increased heat, had de· creased. The flames had destroyei the highly resp<msive sensory fibe~ of the skin and the deeper tissue! were less sensitive to pain. In the stress of excitement - ir automobile crashes, in battle, in foot· ball and in other games - we can Ix seriously injured without feeling the slightest pain at the time. Excitemen• is not the only condition that inter· feres with the perception of pain Whatever alters brain function whether alcohol, shock, or other fac. tor, impairs pain perception. Th brain cells involved in pain perception are selectively depressed bi ancstheitic and pain killing drugi Before other sensory perceptions are seriously impaired, the sensation o pain decreases in intensity. Dr. W. K . Livingston, a pioneer i the study of pain, describes in "Whi Is Pain?" the difficulty of determin ing when the perception of pain be· gins and ends. Using the spectrurr of labor pains, he explains tha given just enough anesthetic to kee her from feeling pain, the woman other perceptions and the thinkin. p::trt of her brain still function. \\'~ Utah Nur ~~ ~ If more a1 istcrecl, the w gle would cea traction of t pressure woul beat quicken. ther increased re piration a!' sponses wouli ne1YeS might signals. The c ingston posed no answer is: l from a light < what point die Pain from < regarded by < other who has jury may find 1 Dr. Irving K . versity in his 1 influences on tolerance amo I talian-Americ is not necessari tients to the de stress, family stress, or other. The Irish , D deny their pai1 tize it. The Ir physician whe1 pointed to a p, Italians were 1 that the pain is cultural group~ centuries diffe pain to serve l provide a shoe! harsh impact ' erty. Even thm of their lives h country, attituc ing with disabil passed along fr another. Besides cultu ception of pain ing to Dr. Beec au tonon1ic ner tory change, ski ing, anxiety an inattention, let! emotion, warm variation, the I hcadcold. Mon threshold, the r: perceived, can Summer, 1969 Pain ... 1ain present? When the anesthetic :lose is increased, there is a depres1ion of the higher brain centers; she becomes delirious, screams and ,truggles as her body makes violent fforts to escape the cause of the pain. She no longer cooperates with the obstetrician and becomes inco1erent. AND ~ tr 104 ing their seared to signify that .eligious enthu:hetic, as it has ttics who have their bodies." rtyrs, the pain, heat, had dehad destroyed ! sensory fibers deeper tissues pain. Kitement - in 1 battle, in foot.es - we can be 1out feeling the ime. Excitement ition that inter~ ption of pain. brain function, :k, or other facierception. The in pain percepdepressed by 1 killing drugs. perceptions are :he sensation of :nsity . ton, a pioneer in ;cribes in "What 1lty of determin1tion of pain be1g the spectrum explains that. 1esthetic to keep in, the woman's nd the thinking II function. Was Utah Nurse If more anesthesia WCl'l' admi1111tercd, the woman's talk and strug~le would cease, but with such conraction of the uterus , her blood ire ure would rise and her heartbeat quicken. If anesthesia were further increased, one by one , heartbeat, cspiration and other physical re1ponses would cease, though the nerm might still transmit sensory 1gnals. The question that Dr. Livingston posed and to which there is no answer is: During this progression lrom a light anesthetic to death, at 11hat point did pain cease? Pain from an injury may be discgarded by one person while an other who has received a simi lar inury may find the pain insupportable. Dr. lr\'ing K. Zola of Brandeis Unirersity in his stud ies of the cultural influences on pain perception and olerance among Boston Irish- and Italian-Americans, concluded that it 1s not necessarily pain that sends patients to the doctor, but rather other itre s. family problems, business itre s. or other. The Irish , Dr. Zola found, tend to deny their pain; the Italians dramatize it. The Irish, when asked by a phy ician where the pain is, usually pointed to a particular location; the Italians were more likely to answer that the pain is "all over." Both these tltural groups have developed over Lenturies different philosophies of pain to serve the same purpose: to 1rol'ide a shock absorber against the 1arsh impact of tragedy and prov·rty. Even though the circumstances ,f their lives have improved in this ountry, attitudes that aided in coping with disability and illness arc still passed along from one generation to Jnother. Besides cultural attitudes, the perrption of pain is influenced, according to Dr. Beecher, by age, sex, race, 1tonomic nervous system, circula0ry change, skin temperature, sweat1g, anxiety and fear, training, bias, inattention, lethargy, suggestion and motion, warmth and cold, diurnal ariation, the passage of time, or a eadcolcl. More than that, the pain threshold, the point at which pain is ·rceil'cd, can be raised as much as Summer, 1969 45 per cent by a loud noise, autosuggestion, hypnosis, or other distraction. Parents condition the attitude of their chi ldren toward pain by being oversolicitous or casual, by transferring their own fear or courage, their tendency to complain or to endure. This parental influence may act as a sort of thermostat that sets at an early age the pain threshold their children will have throughout life . MAN'S EFFORT TO ALLEVIATE PAIN Nothing proclaims the universality of pain so clearly as the means man has used through the ages to prevent or cure it. He has used incantations, prayers, talismans and charms, drugs and radiation, and the knife. He has tattooed symbols on his body to keep out the evi l spirits that could bring pain and has sought through relig-ious ritual to exercise the spirits of pain once they got inside him. All sorts of sacrifices have been made to the gods to put them in a more receptive mood for listening to appeals for mercy. Priests and priestesses have been implored by suffering mankind to intercede with the gods for cure or mitigation of pain. In the Middle Ages, great faith in the efficacy of prayer in itself was a powerful psychological aid in reJie,·ing pain. Man has supplemented incantations, sacrifices, charms and the like with natural medicine, the lore of herbs and leaves, certain tree bark, and other growing things, among them the poppy, mandragora, hemp, and henbane to control the pain of body and spirit and to allay fear, apprehension , and even terror. Pain killers were recorded thousands of years before Christ. In China as far back as 3000 B.C. acupuncture, the picking with needles as a counter-irritant, was used to relieve pain. A remedy for toothache was found on a Babylonian clay tablet dating back to 2250 B.C. Ancient man used opium, surgery, heat, cold, and massage to relieve pain. Even electrotherapy as shock treatment for neuralgia and headache was used through the ingenious application of the torpedo fish. About 200 A.D ., the physician Galen advocated opium and mandragors as well as electrotherapy for the control of pain . During the Dark Ages medicine a a science was largely replaced by superstition and medicine's center of gravity shifted to Arabia where the physician Avicenna, a clominent figure, made a special contribution to medicine by describing some 15 different types of pain and ways of alleviating them, suggestions that became medical guidelines in Europe for six centuries. As the Middle Ages dre\\' lo a close, some advances were made in the use of drugs and therapeutic methods for reducing pain . A popular though unreliable analgesic and sleep inducer was the somniferous sponge which was saturated with the juices of opium. hyoscine, manclragora, and other plants. There was no doubt the sponge's efficiency in inducing sleep. The only trouble was that on occasion the sleep becam<' death. For centuries th..: religious attitudes toward pain as punishment for sins. trials of the just. an opportunity to share something of Christ' suffering, and its general advantages or the soul were attitudes not conduci,·e to extensi\'e research in the nature of pain and ways it could be controlled . It is not surprising that at the encl of the 18th century, the same pain killers - opium. henbane, mandragora - were the \\'iclcly used analgesics that had been used several thousand years before by the Chinese, Egyptians. Greeks. and later by the Romans. Before the first public demonstration of anesthesia on a per cent in 1846. surgeons had to be ironnen·ed. steady, powerful, and swift. Surgery was a last resort, the alter ~ native to death. Pain had to be so intolerable that the need for relief from it was worth the risk of life. In those clays before anesthesia , the contrast between the dissecting room where surgeons studied anatomy on a subject that lay perfectly sti ll and beyond the reach of pain and the ights and sounds of surgical practice can scarcely be imagined. The suraeon in the operating room cut into a fully conscious patient restrained by straps and powerful men. Only speed cou ld reduce the torture. Nor were the indescribable circum stances of cutting into conscious patients the only surgical haza rd up to the l 850's. There was the clanger of infection. Until 1864 when Pasteur discovered the cause of infection, no precautions were taken against it. Menaced by the triple hazard of pain, trauma, and infection, only the hardy su1Yivecl surgery before the mid-eighteen hundreds. In the 19th century, as science and industry transformed this and other western countries, medical practice benefited from new types of equip13 Pain ... Pain .. ment that could be mass produced. For the conquest of pain, a most important development ( 1845-1855 ) was that of the syringe and hypodermic needle that made it possible to inject analgesics. Along with the advances in equipment were the developments in chemistry that lead to the synthesis of certain pain relievers. The introduction of cocaine into medical practice was one of the great boons to man. Though cocaine was well known by South Americans, particularly in Peru and Bolivia where the natives chewed coca leaves to alleviate pain and hunger and to increase endurance, its application in medical practice did not come about until 1884. In what year, the Viennese Carl Koller used cocaine as a local anesthetic for the eye and Dr. William S. Halsted, John Hopkins University surgeon, discovered the principle of block anesthesia, injection of cocaine into a nerve trunk to stop pain. In 1898, spinal anesthesia was introduced into surgical practice. Surgical methods to control intractable pain were developed as refinements in anesthesia and aseptic techniques improved a patient's chances of surviving surgery. As the means of mitigating pain increased, concomitant problems arose. Seriously complicating the control of pain is the tolerance some patients develop to sedative drugs, a tolerance that is prevalent today because of the widespread use of prescription and other drugs, including alcohol. As Dr. Arthur S. Keats, Chairman of Anesthesia at Baylor University, puts it, "This tolerance is the product of tranquilizers during HYLAND PHARMACY 3291 Highland Drive the day, hypnotics at night, and alcohol in between. For some persons it has brought death. A usual dose of hypnotics which is large because of tolerance, after an extra large alcohol intake has led to asphyxia, either by simple respiratory obstruction or secondary to vomiting and aspiration. These individuals are tolerant to narcotic effects as well. ... Despite the lack to logic, chronic users of tranquilizers, hypnotics and alcohol are resistant to potent analgesics." This resistance is especially evident m chronic alcoholics. Timing, Dr. Keats says, is more important to successful pain therapy than is the particular drug or the dose or the interval of dosage. If pain is effectively treated soon after its onset, it should be relatively easy to control. But the longer it remains unrelieved, the greater the patient's and the more difficult it is for drugs to bring pain relief. Of post-operative pain, Dr. Keats says its intensity is related not only to the patient and the type of operative pain, but also to the anesthetic used during the operation. In treating post-operative pain, the physician should consider the curve of pain intensity and adjust the dose and route of the drug accordingly. But what usually happens, according to Dr. Keats, is that all patients get a routine drug and dose without regard for the pattern of pain. It is Dr. Keats' opinion that physicians generally do not like patients who do not obtain relief from powerful analgesics. "The patient continues to complain that he does not have a very good doctor, since a physician is obliged primarily to alleviate pain and suffering. Nor are such patients popular with the nursing staff." 485-9281 RESEARCH AND TRAINING or 466-0787 "The Store With Prescriptionality" DOUG ROTH Reg istered Pha rmaci st 14 T~ough biomedical scientists in many fields have made brilliant discoveries in the past 50 years, pain, its inner nature, its causes and mechanisms, and its psychosomatic aspects have not merely been inadequately explored, but neglected. Not only are present methods of chronic pain control inadequate, but their effect is often temporary and sometimes permanently damaging. A price we pay for living longer is chronic, degenerative disease. A characteristics of two of the most prevalent of these diseases - cancer and arthritis --- is chronic pain. The incidence in intractable pain is rising and, as a concomitant of our in~reased longevity, will continue to increase. Pain research is handicapped in several ways. For one thing, it is almost impossible to devise even the simplest test that eliminates psychological factors; in laboratory studies, the deep, primeval fear of pain and its mysterious portents arc not present. There is quite a difference between pain experienced by a sick or injured person and that which is "induced." The former is subjective and difficult to study by accepted research methods which attempt to find objective evidence to confirm the patient's subjective judgments. Many physicians are understandably reluctant to withhold pain relief or to induce pain experimentally in order to investigate it. Despite the revolutions takin~ place in many areas of science, the ad\·ances, the new subdivisions, and exciting possibilities, there has been a deplorable lack of progress in basic knowledge about the nature and control of pain and, among scientists. a curious indifference to the subject of pain control. Morphine, a derivative of opium, the analgesic stabler for thousands of years, is still the drugs physicians . use most often to control severe pain . In the use of this drug, every physician faces a fearful dilemma, the choice between mitigating pain and the possibility of turning his patient into a drug addict. Scientists have been unable to synthesize a pain killing drug that is as effective as morphine without its addictive property. Dr. Louis Lasagna of Johns Hopkins University has said that, in some ways, certain analgesics developed as morphine substitutes "are perhaps more dangerous than morphine in this respect (merperidine, for one, which is so common a drug addiction among physicians and nurses). The search must continue for a truly nonaddicting morphine substitute. It would be a boon in so many ways. For one thing, it would decrease the number of patients who become "medical addicts," although addiction seldom occurs when drugs arc properly used in the legitimate practice of medicine. It would decrease the diversion of medical stores of analgesics into illicit channels. Most important, a truly nonaddicting morphine substitute would give increases comfort to patients who now suffer Utah Nurse unnecessari hension th and unreas1 nurses, tha create add or its subst. needed to < Even if ; for morph would neec to be of 1 ill, especial] the pains of tom limb" isfactory ~n to which ti not develor a while, ne alleviate pa' The man analgesic al! Dr. Lasagm more analge would be as injected. At b\' mouth r l~rger doses jccted and o predictable. Despite th who suffer c physicians r~ in its treatm two medical the manage: Interns and to consider i According to the few phyi cial interest manage pafa pain. "In thii ical advance of thousand! are not given are mistreate1 to narcotics, longed disal chronic pain mutilated." Perhaps no presents such the nature a1 staggering diJ aged scientists ing more qua] field, Dr. Bor establishment of specialists plan and can tractable pain also provide f< research traini ing. Summer, 1969 Pain ... c pain. The pain is ris1t of our incontinue to dicapped m thing, it is ise even the ninates psylaboratory eval fear of portents arc 1ite a differrienced by a n and that 1e former is to study by :hods which ive evidence .'s subjective understandld pain relief rimentally in tions taking : science, the livisions, and ere has been 1gress in basic nature and ong scientists, :o the subject ine, a derivadgesic stabler s, is still the nost often to the use of this aces a fearful :ween mitigatbility of turnrug addict. unable to synlrug that is as : without its y. Dr. Louis 1pkins Univerime ways, ceriped as morperhaps more phine in this for one, which rug addiction nurses) . The or a truly nonsubstitute. It ;o many ways . .d decrease the who become though addic·hen drugs arc ~gitimate pracrVOuld decrease dical stores of Fhannels. Most laddicting mor~ give increases rho now suffer Utah Nurse unnecessarily because of the apprehension that is at once legitimate and unreasonable among doctors and nurses, that inadvertently they will create addicts by giving morphine or its substitutes as often as they are needed to control pain." £\'en if a nonaddicting substitute for morphine were discovered, it would need an additional property to be of value to the chronically ill. especially those who suffer from the pains of cancer, arthritis, "'phantom limb,'' and other causes. A satisfactory analgesic must also be one to which the chronically ill would not de\'elop a tolerance that, after a while, negates a drug's ability to alleviate pain. The manner of administering an analgesic also influences its efficacy. Dr. Lasagna points up the need for more analgesic that, taken by mouth, ll'ould be as potent as those that are injected. At present, analgesics taken by mouth must be given in much larger doses than those that are injected and often produce erratic, unpredictable, even dangerous results. Despite the vast numbers of peopil" 11ho suffer chronic, intractable pain, physicians receive almost no traning in its treatment and control. One or lll'O medical schools give courses in the management of chronic pain. Interns and residents learn merely to consider it a symptom of disease. According to Dr. Bonica, except for the few physicians who have a special interest in the problem, doctors manage patients afflicted by chronic pain. "In this age of marvelous medical advances,'' he says, "hundreds of thousands of suffering patients are not given relief they need, others are mistreated and become addicted to narcotics, still others incur a prolonged disability because of the chronic pain, and some are even mutilated." Perhaps no other clinical research presents such problems as research in the nature and control of pain; its staggering difficulties have discouraged scientists. As one way of attracting more qualified scientists, into this field, Dr. Bonica has advocated the establishment of centers where teams of specialists would diagnose and plan and carry out therapy for inTactable pain. These centers would also provide focal areas for research, research training, and clinical training. Summer, 1969 At the University of Washington Pain Clinic of which Dr. Bonica is founder and co-director. the medical team consists of four ,anesthesiologists, a neurosurgeon, a psychiatrist, two specialists in physical medicine, two orthopedists, a radiotherapist, one internist, a general surgeon, an oral surgeon, two general practitioners, several nurses, a sociologist, and two social workers. Besides treating patients and being consultants, the group meets each week to discuss difficult pain problems and various aspects of pain. Part of the job of pain control centers would be to train physicians who practice in communities where the facilities for diagnosis and treatment are decidedly limited. After their intensive training at pain control centers, the physicians would be kept informed of new developments and from time to time, would be given refresher training by these centers. The physician most intimately concerned with the control of pain whether in the operating room, in an intensive care unit, or in a clinic is the anesthesiologist. His skill and experience in dealing with surgical or crisis type of pain also qualify him for dealing with the special problems of chronic pain, the use of seditives, analgesics, and other drugs as well as such procedures as nerve blocks. The average anesthesiologist, however, according to Dr. Bonica, needs far more than the routine training if he is to recognize the general manifestations of painful states and their characteristics patterns. He must be able in this era of sophisticated medicine to integrate and interpret neurologic, laboratory and other diagnostic information that may indicate methods for controlling chronic pain that go far beyond the anesthesiologist's purview. He should know what pain control therapeutic and rehabilitative resources exist in his own and in other communities. Though pain is universal, everything connected with its control is in short supply. There are at present no national or regional clearing houses for information about developments in pain therapy. The scientists who study the nature of pain, analgestics, and control techniques including surgery and nerve blocks are but a handful compared to the number of scientists in molecular biology, for instance. The National Institute of General Yledical Sciences, the Federal government's largest unit for supporting basic medical research, was given a mandate by the Congress in 1965 to stimulate more research and training in anesthesiology and other clinical fields. Although the Institute doubled the number of anesthesiology research projects since then, the amount of research on the nature and control of pain is in no way commensurate with the problem, the 25,000,000 surgical procedures a year requiring anesthesia and millions of people suffering every day and night from chronic pain. Because there are simply not enough top-flight scientists in this field of research, the National Institute of General Medical Sciences has followed the only course possible under the circumstances: while supporting the research of present scientific leaders in anesthesiology, it is also supporting the training of selected physicians who will specialize in anesthesiology, and will combine research with practice and teaching. The Institute is also supporting anesthesiology research and training centers where teams of scientists in many disciplines work together on studies ranging from basic molecular research to anesthesia techniques in the operating room. The first of these center grants was awarded in .June 1967 to the Uni,·ersity of Pennsylvania and the second to Harvard University in .January 1968. Dr. Bonica ranks chronic pain as this country's most common disabling disease and estimates that millions of man hours a year are lost through chronic pain. While scientists seek the causes and cures of major diseases, no one knows or even suspects the infini.te number of men , women, and children suffering from diseases and other handicaps of which persistent, inescapable pain is a part. Leriche said we are not all equal before pain. To discover the elusive mechanisms of that type of pain defined by him as a disease and not a symptom, to find ways of controlling th;it pain which serves no purpose, and to improve the safety and efficacy of analgesics in prolonged surgical procedures, and in childbirth , science must now apply modern techniques and tools with a diligence equal to that applied to research on diseases themselves. 15 Attention The " Utah Nurse" commends the Salt Lake Community Nursing Service for having attained National Accreditation Salt Lake Community Nursing Service Receives Accreditation "As of June 18, 1969 the Salt Lake Community Nursing Service was advised by the Board of Review for Accreditation of Community Nursing Services that the Agency had been granted full accreditation." For the purposes of the accreditation program , a community nursing service is defined as an essential component of comprehensive community health services. It provides skilled nursing care and related services to the sick, disabled , and injured, and supportive health counseling on a family-centered basis to individuals, families, and groups in homes, schools, and industry. Community Nursing Services interweaves its services with those of other health and allied workers. and participates in the planning and implementation of community health programs. A community nursing service may be administered by a visiting nurse association, the nursing 1mit of health department. a combination of Yisiting nurse association and health department nursing service, and other types of community organi zations providing nursing service to people outside of hospitals. extended care faci lities, and nursing homes. The criteria for accreditation are based on the foil owing beliefs: I. Organization and Administration As a basic community health resource, public health nursing- should be available on a community-wide basis. This may be provided hy one or more agencies possibly of different types. In today's society, agencies must have legal a uthorization to operate - - with stated beliefs and objectives which reflect the purpose of the agency. Administrative responsibility and relationships should be clearly defined and established. Citizen groups should participate in determining policies. The agency should be alert to the need for frequent evaluation of administrative policies. II. Program Nursing service is planned and provided in accordance with the agency's purpose or objective and in relation to community health needs and to the total health program. Continuing evaluation of progress toward objectives is essential for promoting, developing, and maintaining high quality of community nur sing service. III. Staff The purposes and objectives of the community nursing service are reflected in staff patterns, policies, and practices. Effective performance of the nursing service requires a staff large enov15h to permit employment of supervisory, administrative, and supportive staff. IV. R esources The purposes and objectives of the comm unity nursing service call for the coordination and utilization of a wide variety of appropriate community resources. This may be accomplished by an effective system of communication,contracts, agreements, a nd other cooperative arrangements. Once a nursing service receives accreditation it remains accredited as long as it meets these conditions: submits progress reports as requested by the Board of R eview; presents an interim report within two years of receiving accreditation; compi les a written report every five years. In addition, a site visit is required at five year intervals or more frequently, as determined by the Board of R eview . The voluntary submission to review by one's peers is strong evidence to clients, staff, and funders that the agency is striving for and maintaining quality of service. Utah Nurse 16 . - - - - ---- - ~ Summer, 1969 AMERICAN NURSES' ASSOCIATION APPOINTS HILDEGARD PEPLAU AS INTERIM EXECUTIVE New York, N.Y., July 5 - ·d of full Hildegard Peplau , R.N., Ed.D. , has been appointed as interim executive director of the American Nurses' Association. Announcment was made by Dorothy A. ls an care famunity ,rtici- Cornelius, ANA president, on behalf of the Board of Directors. Dr. Peplau, who will assume her duties with ANA in September, is presently professor and director of the Graduate Program in Psychiatric Nursing at Rutgers, the State University of New trsing nurs- Jersey. ~ tside She will succeed Mrs. Judith G. Whitaker who has held the position of executive director from 1958 to 1969. Dr. Peplau was graduated from the Pottstown Hospital School comtypes. )eliefs id re,te in >f ad- of Nursing, Pottstown, Pa. and later received a B.A. in Interpersonal Psychology from Bennington College in Vermont. She holds an M.A. in Teaching and Supervision of Psychiatric Nursing and an Ed.D. in Curriculum Development from Teachers College, Columbia University, New York City. n· obCon- Dr. Peplau has lectured widely and has had many articles ~' and published in health and education journals. She is author of two books, "Interpersonal Relations in Nursing" and "Professional Experience Record." tterns, · large On May 20, Dr. Peplau received the Alumni Achievement Award in Nursing Practice from the Nursing Education Alumni m and )]ished ve ar- Association of the Department of Nursing Education, Teachers College, Columbia University. Dr. Peplau will be on leave of absence from Rutgers during s these report dition, of Ref, and Utah Nurse her interim appointment with ANA. Summer, 1969 17 Officers Elected at 1969 Convention SECOND VICE PRESIDENT (term 2 years ) . VERLA COLLINS (District No. 1) Education: St. Benedict's Hospital; B.S., University of Utah; M.S., University of California; Post Masters , University of California. Present Position: Director of Nursing. L.D.S. Hospital , Salt Lake City. Utah. Professional Activities: Active in NLN, CNA, ANA and USNA. Member of USNA Continuing Education Committee and Commission to Study Nursing in Utah. TREASURER (term 2 years) DORIS MAISAK (District No. 2) Education: A.D .. Weber College; Continuing Ed., WICHEN. Present Position: Head Nurse, Intensive Care, Thomas Dee Memorial Hospital , Ogden, Utah. Professional Activities: Dist rict 2 Board Member ; USNA Board Member, USNA Com·cntion Chairman. BOARD MEMBER (term 2 years ) ELMA HUMPHREYS Education: (District No. 2) Thomas Dec Hospital ; Continuing Education , Weber State College and Uni,·crsity of Utah. Present Position: Supervisor, Ogden City School Nurses, Ogden, Utah. Professional Activities: District President; President, Dee Alumni: USNA Board Member. RA YOLA A DERSEN - Memorial Hospital (District No. 1) Education: LDS Hospita l: B.S ., University of Utah; M.S. in June, University of Utah. Present Position: Graduate Student, Assistant Director of Nursing, LDS H ospital. Salt Lake City. Utah. Professional Activities: !'<SA Section. Headquarters Committee, Incumbent Board Member. NOMINATING COMMITTEE U.S. D (term one year ) SISTER MARY RACHAEL Educ:ition: (District o. 2) St. Cathcrine·s School of ~ursin g; St. Paul. Minnesota. B. :\ .. Major in Nursing. Prese nt Position: Operating Room. St. Benedi ct's Hospital. Professional Activities: Board Member. Distri ct No. 2; Active Member, Utah State :\urses· Associa tion . JANEY BROWN B.S. , Uni,·ersity of Utah ; Continuing Education; National Training Laboratory Workshop, College of Southern Utah, Cedar City, Utah. Present Position: Nursing Sen·ice Education Director, Holy Cross Hospital, Salt Lake City, Utah. Professional Activities: District Chairman. Nominating Committee; State Chairman. USNA In-service Educators Conference Group; Representati,·c to Aduh Council on Higher Education of Salt Lake Basin: USNA Continuing Education Committee. WILMA BO TEY 18 (District No. 1) Education: (District No. 3) Educat ion: BYC. B.S. 1\ursing. Present Position: Staff l\ursc. Surgical Unit, Utah Valley Hospital. Pro,·o. Utah. Professional Activities: .\ctivc USNA Member. Utah Nurse Summer, 1: ~estions & vfnswers on i\·ersity of Utah: ta!, Ogden. Utah. ·ague for :'\ursing, ~be/la vfary' s of Wasatch ; .ncisco. irsing, Holy Cross strict # 1; Mater- ity of Utah ; M.S ., State Division of The following questions and answers on rubella and the new, live rubella virus vaccine are based on prelicensing recommendations for vaccine - use prepared by the Public Health Service's Advisory Committee on Immunization Practices in collaboration with the "Red Book Committee" of the American Academy of Pediatrics. !siden t; Chairman, mber of U.S.N.A. l.egislative Council. ; B.S., University eac hing Certifi ca te D epartment, D ec ·ogram Chairman ; .ttee, Publi c R ela- Nursing. H ospita l, Ogden , U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service U tah ; Continuing Hospital. L-..:::;:=::=::_...~~-'-...C.....-~~~~~-=:::;;::;::::::::;::::=---=----=:;;:::::;;::;:::::;::::::;::::=:;;:;;:::::::::;::::::::::;::::==- r o ess1ona Act1v1t1es: zstnct oar cm er, . 'om111a t111g Committee ; State U S'.'IA Genera l Duty Chairman, Vice Chairman, M emberat- La rgc. CORALLENE McKEAN (CEASR ) - (District No. 1) Education: Salt Lake Genera l Hospitai ; B.S., University of Utah New York University, Continuing Education University of Utah. Present Position: Executive Director, USNA. Professional Activities: District , Careers, Program ; State President Utah League for Nursing, C a reers Chairman, EACT. ELAINE MURPHY (E .A.C.T. ) -- (District No. 3) Utah Nurse Summer, 1969 Education : University of Utah , B.S. ; University of Utah , M.S. Present Position: Actin g D ean , Brigham Young University College of Nursing. Professional Activities: Distric t Structure Study Committee ; State Chairman Structure Study Committee, Utah Professional R elations Committee, WICHEN, Phi Kappa Phi , Sec. Baccalaureate Seminar, University of Utah College of Nursing Honor Association . 19 Q. WHY IS RUBELLA - ONE OF THE MILDEST INFECTIOUS EASES - IMPORT ANTI Officers Elec Rubella, or German measles, is well recognized to be a common relatively unimportant illness of childhood. When adults get the di especially women , they can experience arthralgia or arthritis, but e1 then the disease is not particularly severe. The real importance of ru lies in the ability of the rubella virus to cause serious anomalies in developing fetus, principally during the first trimester of the mot pregnancy. The anomalies range from minor ones to those which thre life or are actually incompatible with it. Some of the comm recognized defects of the congenital rubella syndrome are catar cardiovascular defects , deafness, mental retardation . ...c VERLA COLLINS - ( Education: Present Position: Professional Activities: Q. DOES RUBELLA HAVE A PATTERN, A SEASON, A TARGET? Most cases of rubella are in schoolage children and occur particu frequently during the winter and spring months . By early adul approximately 80 to 90% of individuals in the United States serological evidence of immunity. DORIS MAISAK -- (D Education: Present Position: Q. CAN YOU FORECAST EPIDEMICS AND THE LIKELY NUMBER ASSOCIATED CONGENITAL ANOMALIES? Professional Ac ti vi ties: ELMA H UMPHREYS Education: l Present Posi t ion: S Professional Activi ties: £ A c RA YOLA ANDERSEN ___, Education: I l Some rubella cases occur each year . But epidemiologists describe spread epidemics every 6 to 9 years in the United States. Presumably result from the susceptibility of the population increasing to a en point. Our last major epidemic, in 1964 , was probably the larges: about 30 years . As a result of the 1964 experience, it's estimated 20 ,000 to 30,000 infants were born with severe congenital anomali the cyclical character of rubella epidemics persists, we could expect t another increase in cases as early as 1970 or as late as 1973 . Many feel because of the size of the 1964 epidemic the next experience with ru should involve considerably fewer cases than in 1964. In individu< determine t young adul certain that least 2 m< performed a need for va require assu method . n experience , Q. ARE THE RUBELLA As with mo the attenua diseases sue resistance radiation . illnesses , un in various c known hyp The vaccine to persons Until the r vaccines . U from other I . ARE THE VACCINA As we en te rube ll a infe Present Position: G I protecting Little was known about the rubella virus until 1962 when 2 grou Professional Activi ties: !\ rubella . Th United States scientists isolated it in their laboratories. It then h ~ underlying possible for the first time to investigate the disease in detail an done by car NO interpret the immunity following infection. Beginning immedii of m o the rs workers in this country and in other parts of the world began the ard way we can task of attempting to attenuate or tame the virus into a suitable form SISTER MARY RACHA' progress to w vaccine . St·-~~~~~~:--·........~~s>-oTo-r-mrr.-irvrncrrre~-:r.-~~~~~~~~""""'!'!!!!!l!!!!llii~'l!'9'~~~--l Education: Q. HOW LONG HAS THE DISEASE BEEN UNDER INVESTIGATION~ IL\ .. Major in Nursi;g. Present Position: Operating Room. St. Benedict' s Hospital. Professional Activities: Board Member. District No . 2; Act ive Member, U tah State :'\urscs· Association. J ANE Y BR OWN - B .S ·: U · · of U ta h ; Contin ui ng Ed ucation; Na tiona l . n l\·ers1ty Tra111111g Lab~rato ry W orksh op, College of Sou thern Utah, Cedar City, Utah . Present Posit ion: Nursing Sen:ice Education D irector, H oly Cross H ospi ta l Salt Lake City, U tah. ' Professional Activities: D istrict Chairman. Nomina ting Committee; State C hairman. USN.A I n-service Ed ucators Conference Group· Represcntatl\·e to Ad uh Council on Hi gh er Educat ion of Salt Lake Bas111: USNA Con ti nu ing Ed uca tion Commi ttee. WI LMA BONEY 18 (District No. 1) Education: (District No. 3) Education: BYU. B.S. :\ursing. Present Position: Staff Nurse. S urgica l Uni t, U tah Vall ey H ospita l. Pro,·o. Utah . Professional Activities: .\ cti\·c USNA Member. Utah Nurse Summer, ts . IF A YOUNG ADULT WOMAN SERIOUSLY REQUESTS RUBELLA VACCINE, SHOULD IT BE DENIED? In individual cases , a physician could consider such requests if he could determine that vaccine was needed realizing that only 15 to 20% of young adult women remain susceptible to rubella - and if he could be certain that she was not pregnant and would not become pregnant for at least 2 months following immunization. Optimally , a competently performed and interpreted HI antibody test should be used to establish the need for vaccine . Then , if vaccine is to be given , the physician should require assurance that pregnancy will be avoided by a medically acceptable method . The patient can be alerted to the likelihood that she could experience arthritis or arthralgia beginning 2 to 3 weeks after vaccination . i\'ersi ty of U tah : tal, Ogde n . U tah. ·ague for !\ ursi ng, 1lary' s of Wasatch ; ncisco. 1rsing, Holy Cross so~.~ 1~RG£'I'1 ARE THERE SOME OTHER PEOPLE WHO SHOULD NOT RECEIVE UBELLA VACCINES? \>attic " and occut\'f auu\ Ute" eat t\\S· Y,'f .\ State~ on \jni.teu i.n t\\e s with most live virus vaccines, rubella vaccine should not be given where e attenuated virus infection might be potentiated by severe underlying eases such as leukemia, lymphoma, or general malignancies , or where istance has been lowered by therapy with steroids, other drugs, or iation. Vaccine should be withheld from children with severe febrile ~ esses, until they have recovered. Because the vaccine will be produced n -r\\£ arious cell cultures, it should be given with caution to individuals with v . wn hypersensitivity to the species from which the cells are derived . i£S'1 ·sts uescn vaccine contains a small amount of neomycin and should not be given t e\)i.uern\o\o!s . yresurt\ rsons known to be sensitive to this antibiotic . il\'6 to u ·tell Sta t\\e \)nt . on 1nc1eas t\\e \ the results of carefully con trolled clinical investigations are known, no\>u\at\ ,...1obab\'f <ti accine should not be given simultaneously with other live virus r was r ·fs e• \964 , er\ence, 1 ·ta\ an es. Until then it would be reasonable to separate rubella vaccination \964 er.\> ere conient \d et' ther live vaccines by at least 1 month . it\\ se'I we cou nw. ers\sts, 91'3. M.a 1detn1cs \> \ate as\ · ce HERE PLANS TO EVALUATE THE EFFECT OF RUBELLA t er.\>enen 910 or as \ . t\\e ner. 'NATION ON THE INCIDENCE OF ANOM:ALIES? . deft\\C · \ 964 · \>1 tnan 1n r cases nter an era of rubella control through vaccination , surveillance of \~£5'\:\G~jnfections becomes particularly important. Our ultimate goal is £~ \J~u£R nen'lg pregnant women and their offspring from infection with S£ y,£ "ti\ \96'1.W \t Therefore, we must make particular effort to identify the ·ru<> u" t nes. i.n dg causes of all observed congenital anomalies. This can best be \)e\\a '1\ . \abota 0 ~d i.t in .t\\e\t t\\e u\seas.e nin'b tarefully interpreting the mothers ' illnesses, by laboratory studies t in'1estw,a;e ti.on · \)e~n\,\ ne'b' and infants, and by reporting all resulting information. In this to ·niec or u "\owi.n'b 1 ot thew oui.t\n learn the true incidence of rubella anomalies and evaluate our \oi arts ·1 to a • ·n 0 tnet \> ne ..,1rus n ward adequate control of this primary hazard of rubella. d\ tarne t uate ot ro ess10na ct1v1t1es: zstnct oar cm er, 1 'om m a tmg \,\~£\,~ ~ strict # 1; Mater- ity of Utah ; M .S., Sta te Division of !sident ; Chairman, mber of U.S .N .A . :..egislative Council. ; B.S., U niversi ty Ce rtifi ca te ~ ac h ing D epa rtmen t, D ec ·ogram C ha irm a n ; ttee, Public R ela - N ursing. H osp ita l, O gd en , U tah ; Continu ing H ospit al. Comm it tee; S tate U SNA Gene ra l Duty C ha irman, Vi ce C h a irma n, M embera t-La rge. CORALLENE McKEAN (CEASR ) - Salt La ke General Hospital ; B.S., University of Utah New York University, Continuing Education University of Utah. Present Position : Executive Direc tor, USNA . Professional Activities : District , C a ree rs, Program ; State President Utah League for N ursing, Caree rs Chairma n, EACT. ELAINE MURPHY (E.A .C.T .) - Utah Nurse Summer, 1969 (District No. 1) Education: (District No. 3) Education : U niversity of Ut ah , B.S.; University of Utah, M.S . Present Position: Acting Dea n, Bri gh am You ng University College of Nursin g. Professional Activities: D istric t Structure Study Committee; Stat e Chairma n Struc ture Study Committee, Utah Professional R ela tions BacC ommittee, WICHEN, Phi Kappa Phi , Sec. ca la ureate Seminar, University of Uta h College of Nursing H onor Association. 19 A.N.A. DELEGATES EVA JEAN LAW (NSA) -- (District No. 2) Education: Pocatello General Hospita l : B.S ., Uni,·ersity of Utah: M.S .. Uni\'crsity of Utah. Present Position: Director of Nursing. M cK z.y-Dcc H ospita l, Ogden. Utah. Professional Acti\'ities: District ac ti\'c member : State Utah League for '.\ursing, H eadquarters Committee , Presiden t. FAY FRASHKE (M.C.N. - E.A.C.T. ) - (District No. 1) Education: Holy Cross School of Nursing; B.S., St. Mary' s of Wasatch ; M.S ., University of California, San Francisco. Present Position: Associate Director Instructor in Nursing, Holy Cross Hospital School of Nursing. Professional Activities: Past Treasurer and Board Member, District nal-Child Nursing Conference. VIRGINIA COLE (P.H. - N.S.A.) - # 1; Mater- (District No. 1) Education : University of Minnesota ; B.S., University of Utah; M.S ., University of Utah. Present Position: Assistant Director of Nursing Utah State Division of Health. Professional Activities: Past U .S.N.A. Board Member and President ; Chairman, Public Health Study Committee; Member of U.S.N.A. Advisory Council; Secretary, Women's Legislative Council. RUTH BROWN (Psych. - N.S.A. ) - (District No. 2) Education: D ec Memorial H ospita l, Ogden, Utah; B.S., Uni\'ersity of Utah; M .S., U ni,·ersity of Utah, T eaching Certificate in M cd-Surg, University of Washington. Present Posi tion: Clinical :'forsing Directo r of Psychiatric D epartme nt, D ec Hospita l. Ogden, Utah. Professional Activities: D istrict President. Boa rd M ember, Program Chairman ; State SNA U Ad,·isor. Ad,·isory Committee. Public R elations Commi ttee. BARBARA TUCKER (N.S.A .) (District No. 2) Education : B.S .. Uni\·ersi ty of Cincinnati College of Nursing. Present Position: H ead Nurse , M ed ica l Di,·ision, D ec Hospita l, Ogden, U tah. Professional Activities: Di stri ct Acti\'c M embe r. DWELFARE ANN MATHEWS (G.D. ) - JNISTRA TJON (District No. 6) Edu cation: Wm . Budge Memorial Hospita l. Logan, Utah ; Continuing Edu ca tion MCN. Prese nt Position: He ad :\'ursc - Professiona l Activities: District Board M embe r, '.'lominating Committee; State USNA General Duty Chairman, Vice Chairman, Membcrat-Largc. Obstetrics, Logan LDS Hospital. CORALLENE McKEAN (CEASR ) - Salt Lake General Hospital; B.S., University of Utah New York University, Continuing Education University of Utah. Present Position: Executive Director, USNA. Professional Activities: District , Careers, Program; State President Utah League for Nursing, Careers Chairman, EACT. ELAINE MURPHY (E.A.C.T. ) - Utah Nurse Summer, 1969 (District No. 1) Education: (District No. 3) Education: University of Utah , B.S. ; University of Utah, M.S. Present Position: Acting Dea n , Brigham Young University College of Nursing. Professional Activities: District Structure Study Committee; State Chairman Structure Study Committee, Utah Professional Relations Committee, WICHEN, Phi Kappa Phi, Sec. Baccalaureate Seminar, University of Utah College of Nursing Honor Association. 19 Hypnosis Demonstrated An interesting and informative talk and demonstration on hypnosis was given by Dr. W. S. Thain, M.D. , at the District #6 Spring banquet. Congratulations were extended to Dr. Thain for his recent award of "Elk of the Year," presented by the local Lodge. H e is also presidentelect of the medical staff of the Logan LDS Hospital. Forty-five nurses and guests enjoyed the atmosphere of the ew Summit Restaurant at the Smithfield Country Club for the banquet on April 14, 1969. Door prizes were donated by local merchants, plus a drawing for an afghan made by District nurses as a money making project. lnt ensivl' Care Opening D elayed The intensive care unit al the Logan LDS Hospital is ready for use, but because husbands are graduating in this college town, many nurses have resigned to join their husbands in new jobs in other cities and states. The opening of the ICU has been delayed because of resulting staffing shortages. " More extensive care" Communications between the local hospital and public health depart- Heall ment have expanded and improved. More patients are being discharged from hospital care to continue with care from public health nursing visits. The improved continuity of nursing care helps patients to achieve more complete recovery. (Pre z·.s ..\'. Yly pl two aspt A ge nci e~ District #6 Reporter by Prop< pccts an work an to upho. the ~m after th how the into the I!LETA NORRIS Nursing League Appoints Public Health Director The National League for Nursing has appointed Leah Hoening, until recently director of the Bureau of Public Health Nursing, New York City Department of Health, as director of its Department of Public Health Nursing. Miss Hoenig will assume her new duties in June, succeeding Hedwig Cohen upon her retirement. Miss Hoenig will direct League activities to improve nursing care of patients in their homes. These include national accreditation of public health nursing services cosponsored with the American Public Health Association, consultation, studies, publications, and national assistance and guidance to home health agencies. The e nursing E industry, to obey cstablishe therefore, necessary Ev cant Vle\V Fresca tastes like Fresca is DIFFERENT EDUCATIONAL OPPORTUNITIES University of Utah College of Nursing Subject: "HUMAN GENETICS" (Descriptive Genetics) The Course Includes: • • • • • • • Physical basis of heredity - genes and chromosomes Genetic coding Monohybred and dihybred inheritance Sex linked inheritance Test of significant linkage Multiple alleles Quantitative Inheritance etc: Schedule: Fall Quarter - September 29, 1969 Days: Monday - Wednesday - Friday Time: 1 :00 P.M. Registration: Limited AMERICAN FORK HOSPITAL 350 East Third North American Fork, Utah Telephone: [phone] Bed Hospital 4 Bed Coronary & Intensive Care Unit Eligibility: R.N. B.S. For Further Information please contact: Tomiye Ishimatsu, Assistant Professor Maternal-Child Nursing - Graduate Division 25 South Medical Drive College of Nursing University of Utah Salt Lake City, Utah Phone: [phone] Serving Northern Utah County Utah Nurse re,·ie she pract she/f The as to licens fully rent state it is C' out n for f have copy sonne nurse~ nurses Upt nurse, space each F each nurse is the ceives With provid who r a part to pra state. ~ lie, vi nurse ployees It is that a all CU - See cense posted. throug have b be esta Health Agencies Role in Support of the Nurse Practice Act (Presented by Eva Jean Law, 1·.s ..V.A. Pr<'sident at the T w o-Way :s like is ENT ~ RK .,are Unit aunty Utah Nurse Radio Prof!.ram ) :'v!y plan of presentation will cover two aspects under the topic: Health Agencies' Responsibilities to Support by Proper Implementation. These aspects are: ( 1 ) procedures or framell'ork an institution or agency takes to uphold, support, and implement the \f urse Practice Act, and ( 2 ) after the framework is established how the licensed registered nurse fits into the over-all plan: The Agency: The employer, whether hospital, nursing home, public health agency, industry, or such - has an obligation to obey the law which has been established to protect the public ; therefore, the following actions are necessary: Every registered nurse applicant should be personally interviewed and the application form reviewed to make certain he or she has a current license to practice nursing in the state she/he is seeking employment. The license should be examined as to its being proper, ie, the license number should be carefully scrutinized as to the current series being issued in the state and also to make certain it is current for this year. A wayout number is sometimes a clue for fraudulent behavior. (We have recently put a photostat copy of the license in the personnel folder of all registered nurses and licensed practical nurses in our institution. ) Upon hiring the registered nurse, the employer provides a space such as bulletin board, on each patient care unit, or within each department where the nurse can post her license. This is the larger copy the nurse receives upon issuance or renewal. With the license displayed it provides assurance to anyone who may want to know that a particular person is licensed to practice nursing within that state. This can be patients, public, visitors, physicians, other nurse co-workers and other employees. It is very necessary each year that a follow-up be done with all currently employed nurses - See that the current year license is being displayed or posted. A method of following through on those nurses who have been issued permits should be established. All applicants seeking employment who do not have a license should be directed to the State Dept. of Registration or State Board of Iursing so that the process of obtaining licensure can be obtained without undue delay. The agency and the individual need to be aware that there is a time lapse involved because all forms have to be completed and returned to the State Board. This requires sending the forms to the original educational institution where the nurse graduated and to another state board of nursing. This is why it is so important for individual nurses to begin making application whenever they are planning a move from one state to another. If delays can be avoided the nurse is relieved because needed finances do not stop, and the agency is grateful because they can fill a vacancy right away. Many times foreign nurses make their first written inquiry about employment with the employing agency. Foreign applicants should be directed to the American Consul in their own country. The appropriate visa or visitor status has to be obtained. Then after that they should be directed to the board of nursing in the state they are seeking employment. Each state board will then evaluate their credentials and make recommendations. Each institution or agency should have a written philosophy an d stated objectives. There should be general regulations and policies governing the behavior of its employees in its plan of operation. 4. Personnel policies should be established providing correct procedures such as reporting off and on duty - hours of working, personal conduct, sick time, annual leave, etc. 5. Procedure and policy . manuals should be available for all employees. These should be for the specific nursing procedures as well as nursing's relationship to other departments such as the preparation of patients for x-ray or lab, etc. 6. There should be a written plan of care for each individual patient, with evidence that registered nurses are providing the leadership in developing the plan, implementing- it and providing for evaluation. 7. The institution provides current reference library materials within easy access to nursing service personnel. 8. There should be an established inservice education sys t em whereby orientation for new employees can be carried out plus ongoing continuing education for all nursing personnel. These can be formal or informal. (continued on next page ) Nursing Service operates within the framework of the philosophy of patient care which leads to the development of policies and procedures for the nursing department. l. There is a definitive statement of philosophy and objectives. 2. An organizational p lan should be established - providing for communications departmentally and inter-departmentally. 3. Job descriptions should be written for each category of worker within the nursing department and placement of personnel should be according to licensure, educational background and competency of the employee. " SERVICE TO THE PEOPLE OF UTAH " * Competitive Salaries * Advancement Opportunities * Reduced Tuition * Reduced Rates on University Athletic and Theatrical Events * Research Rehabilitation and Clinical Units 50 N . M edica l Dr. - Ph. 32 8 -3711 Sa lt La ke City 21 "Assign competent person" U.S.N.A. Responsibilities and the Nurse Practice Act 9. There should be established a medical nursing practice committee in each institution or agency - to explore the roles and responsibilities of the doctor and nurse in certain procedures and to establish criteria and guidelines for practice in questionable areas. I 0. There is an established mechanism for the reporting and handling of unethical, incompetent, or illegal practice. The Individual Nurse: Within the established proceding framework of the hospital or agency, the nurse working within such, should then: Understand and support the philosophy and objectives of the institution or agency. Know the lines of communication within the agency or institution. Familiarize herself with the standards a n d scope of her duties within the institution or agency. Know and understand the scope and sphere of work allocated to each category of worker. She should not assign duties to persons she knows are incompetent to perform or lack sufficient education or experience to perform. Not accept delegated responsibilities in which she does not consider herself competent or adequately prepared to carry out. Keep herself informed and continuously up-graded in the performance of skills by whatever means are available to her. Be fully aware of the state laws governing practice in the health care field and of the employing agencies' policies regarding incompetent, unethical, or illegal practice. At all times she conducts her practice, her behavior, and relationships within the "Co de for Nurses." Laws are made by man for man. Utah State Nurses' Association the official voice of the expert practitioners is responsible for promoting legislation relating to its practice which will provide the best possible protection of the public health and welfare. U.S.N.A. Headquarters has a new phone number 328-1015 22 The public, and the practitioners, are best served by legislation that is based upon principles which have official professional approval. The people should not be expected to have to differentiate between competent and incompetent practitioners. It should be the function of the nursing profession to fulfill its social responsibility by assisting the public to secure protection through the promotion of adequate nursing practice. This protection is provided for the health of the people by establishing minimum standards which qualified practitioners must meet. Inherent in this process is the fact that each professional nurse obligates herself to support the legal body, State Board of Nursing, as they judiciously implement the standards. In the interest of the public, the professional association submits to the Governor for his consideration the names of those licensed registered nurses who are best qualified to be appointed to the State Board of ursing. Another area of great concern is the need for continued learning to update knowledge and skills in specific areas of practice so that nurses will indeed be safe practitioners! The USNA Board of Directors has asked the Education Committee to develop a proposed plan for recertification. It is anticipated that there will be grassroot discussion in this area. Corallene McKean Executive Director Continuing Education U of U College of Nursing Jun e 1970 Spring 1970 Winter 1970 * School Nursing Supervision and Administration Medical Surgical Nursing·xPsychiatric Nursing·X- Grant funds for fees and tuition may be avai lable. A.N.A. Announces Clinical Conferences "Prospects for Practice'! .. Prospects for Practice" will be examined at the 1969 clinical conferences sponsored by the American Nurses' Association, the professional association for registered nurses. The sessions will be held Nov. 5-7 in Atlanta, Ga., and Nov. 17-19 in Minneapolis, Minn. ''Prospects" will focus on the role of the individual practitioner in determining directions for her practice, according to Elizabeth M. Plummer, chairman of the planning committC'e. Miss Plummer is director of the neurological-neuro-surgical nursing program, gradt~ate schoo~ of nursing, New York (city) Medical College. The primary purpose of ANA' clinical conferences, Miss Plummer notes, is to help nurses improve their practice -- to go "one step beyond" their present level of practice. "The 1969 session are being designed so that participants can explore, question critically examine their own practice in light of social land professional change," she says. "Emphasis will be placed on the exchange of information and ideas with other practitioners." The 1969 ANA conferences will feature clinical papers by nurses representing five areas of practice: community health, geriatrics, maternal and child health, medical-surgical, psychiatric and mental health The speakers will report on recent research or studies and discuss their implications for practice or describe new approaches to nursing problems The program will also includ special interest group discussions on a variety of topics, general sessions on how to deal with change, an general clinical sessions on issul'S o problems in specific clinical areas. The three-day conferences are open to AN A members and aS&>ci ates and to members of the Nationa Student Nurses' Association, for registration fee of $25. Of C/11 A micrc material k1 some has nothing ne1 one in pra .would not I have two. be one sue preparing death sente of eight nu is Daniel ] Paris on a dered a pn tend that stand trial soma! abrn court has a perts, inclu and one of geneticists, advise it. The theo mality may social beha1 \'iolence is tively simp to prove. T rests upon prisons sam, and Austral mates with has been fo1 the general tions to the knows the t1 Y abnormal it is shown how the sec. sonality,let . Supermal1 man and we somes per somes, whi1 characteristi two gonosor In the femal in the male a sperm fr supplies ha!J the combin grow into a tains an X gets that : mother, anc the sperm c< the baby ge the mother; powers the s normally, X Further information on registra tion and program content will be released from the office of Audrey Spector, ANA clinical conferenCt'S coordinator. But somet arc dividin. chromosome· duplicates of up. Instead two neat ro1 Utah Nurse Summer, 196! Genetics Of ractice" ice" will be inical confere American professional nurses. The Nov. 5-7 in v. 17-19 in s on the role ctitioner in or her praclizabeth M. the planning er is director euro-surgical 1ate school of ity) Medical se of ANA's iss Plummer improve their step beyond" ractice. "The designed so xplore, quese their own ial land prosays. "Emon the exn and ideas ferenccs will by nurses reof practice: "atrics, matermedical-surgiental health. ort on recent discuss their ce or describe sing problems. also include discussions on neral sessions change, and on issues or nical areas. nferences are rs and associf the National iation, for a on r~tra ntent will be ice of Audrey 1 conferences Utah Nurse Chromosomes and Crime A microscopic piece of genetic material known as the Y chromo\Qme has made headlines. It is nothing new or rare; every man has one in practically every cell, or he .would not be a man. But a few men have two. Richard Speck is said to be one such; his attorneys are now preparing an appeal against his death sentence for the 1966 slaying of eight nurses in Chicago. Another is Daniel Hugon, awaiting trial in Paris on a charge of having murdered a prostitute. His lawyers contend that he is mentally unfit to stand trial because of his chromosomal abnormality, and the Paris court has appointed a panel of experts, including both a psychiatrist and one of the world's most brilliant ~eneticists , Dr. J erome Lejeune, to adl"ise it. The theory that a genetic abnormality may predispose a man to anti\Qcial behavior, including crimes of 1iolence is deceptively and attractirely simple, but will be difficult to prove. The argument in its favor rests upon the fact that in a few prisons sampled in the U.S., Britain, and Australia, the proportion of inmates with an extra Y chromosome has been found to be higher than in the general population. The objections to the theory are that no one knows the true incidence of the extra \' abnormality, and that even when it is shown to exist, no one knows ~ow the second Y can influence per\Qnality,let alone criminality. Supermale? Nature intended every man and woman to have 46 chromo;omes per cell: 22 pairs of auto;omes, which determine countless haracteristics other than sex, and two gonosomes or sex chromosomes. In the female, these are a pair of Xs ; mthe male, an X and a Y. When sperm fertilizes an ovum, each 1upplies half the 46 chromosomes for the combination of cells that will ,row into a baby. If the sperm conains an X chromosome, the baby ,ets that X plus one from the mother. and will be an XX girl. If he sperm contains a Y chromosome. ne baby gets that plus an X from ll' mother; the potent male Y over\l11crs the single X, and it's a boy ormally, XY. But sometimes, when the first cells .e dividing and both lines of 1romosomes are supposed to make .uplicates of themselves, nature slips 1p. Instead of splitting them into 1wo neat rows of 23 each, it leaves an extra X or Y in one row. If the supernumerary is an X , the baby has an XXY and will grow into a sterile, asthenic "male'', usually with some breast enlargement and mental retardation - a condition that physicians call Klinefelter's syndrome. This has been recognized since 1959. D espite the factor of low intelligence, it has not been linked with criminality. If the extra chromosome is a Y, the baby gets an XYY pattern and is unquestionably male. Or, as evidence gathered by an all-woman team of researchers in Scotland now suggests, he may be a supermale, over-aggressive and potentially criminal. Dr. Patricia A. Jacobs and her colleagues working at Western General Hospital in Edinburgh knew that a number of mentally defective men with a double dose of both sex chromosomes, or XXYY, had been found in Swedish and English institutions as criminals or hard-to-manage inmates.* This made the researchers wonder whether it was the extra Y that predisposed the men to aggression. They decided to check on simpler, XYY cases, previously seldom reported. Among 197 inmates at Carstairs State Hospital, they found no fewer than seven XYY men, or 3.5% (as well as one XXYY ) . This, they estimated, was 50 to 60 times the normal incidence. To check this estimate, the Edinburgh investigators examined 266 newborn boys and 209 adult men without finding a single XYY. In a random collection of 1,500 karyotypes, they found only one XYY. The XYY inmates averaged 6 ft. 1 in. tall, whereas the average for other Carstairs inmates was 5 ft. 7 in. In Melbourne, Dr. Saul Wiener found that the same was true of four Australians, all XYY, who were doing time for murder, attempted murder or larceny. Dr. Mary A. Telfer of Pennsylvania's Elwyn Institute found five XYY abnormalities a mong 129 inmates at Pennsylvania prisons and penal hospitals selected for study because of their height. Property Offenses The consensus so far among the few investigators who have studied the problem is that an extra Y chromosome seems to be associated with below-average intelligence, tall stature and severe acne - traits that might result from the hormone-stimulating effects of the duplicated chromosome. But little more is known about the Y chromosome's effects. Dr. William Price, who works with the research group in Edinburgh, doubts that the XYY pattern can be linked with crimes of violence or sex. Among the XYY men studied at Carstairs, he points out, the proportion whose offenses were against properly - such as petty theft a nd housebreaking - was greater than that among convicts generally. The XYY males, according to Price, do not suffer from brain damage, epilepsy, or any recognized psychosis such as schizophrenia. They are psychopaths, also called " unstable and imsociopaths mature, without feeling or remorse, unable to construct adequate personal relationships, showing a tendency to abscond from institutions and committing apparently motiYeless crimes, mostly against property. " Scotland's XYY convicts tended to get into trouble earlier (around age 13 ) th an the average (about 18 ) . But among their siblings there was a n unusually low incidence of criminality. And in the only case so far reported of an XYY with several children, the abnormality was not transmitted: an Oregon XYY has had six sons, but all have a normal XY pattern. Orthomolecular Minds \i\lhether or not a man's genes may predispose him to criminal tendencies. Chemist Linus Pauling believes that they may have a lot to do with his mental state. This has been proved for a few relatively uncommon conditions such as phenylketonuria (PKU ), in which a defective gene leaves the baby unable to metabolize phenylalanine. The resulting metabolic upset damages the brain and causes mental retardation. But Dr. Pauling would go much farther. In Scinzce, he suggests that because of genetic as well as environmental differences, some people may need more of certain vitamins or other essential nutrients than others. If they have a deficiency, it may selectively affect the brain, producing what he calls a sort of "cerebral scurvy" or "cerebral pellagra." Dr. Pauling, 67, now on the faculty of the University of California at San Diego, won the 1954 Nobel Prize in chemistry for his monumental work on the chemical bonding of atoms into molecules. Lately. he has won more attention (and a second Nobel Prize) as an antiwar crusader. But Pauling remains ·· a chemist at heart, and has long been fascinated by that most elusive of chemical puzzles. the workings of the brain. (con tinu ed on next page) 23 Summer, 1969 -~-- -- - - - - -- - --- - - - - - - - - - - - - - - - - - - - - --- Genetics (continued) Mental Malnutrition The importance of many vitamins to human health, although commercially overexploited, is well documented. What has been too often overlooked, Pauling complains, is that most of the vitamin-deficiency diseases, such as scurvy, pellagra and pernicious anemia, give early warning of their onset. Months or even years before the physical signs appear, there are changes in mental processes. To Pauling, this suggests simply that the brain is more sensitive than most other organs to even a mild deficiency. He would also widen the range of emotional illnesses for which biochemical causes, or at least components, should be sought. Pauling believes that varymg needs for essential brain nutrients, the result of genetic differences, may lead to insufficient production of a normal metabolic product, or to its inadequate utilization, or to a too rapid rate of destruction. "I believe," says Pauling, "that mental disease is for the most part caused by abnormal reaction rates, as determined by g-cnetic constitution and diet, and by abnormal molecular concentrations of essential substances. Significant improvement in the mental health of many persons might be achieved by the provision of the optimum molecular concentrations of substances normally present in the human body." Just what these optimum concentrations may be for any individual, Pauling does not pretend to know. It will take a massive research effort over many years to find out, and to find out whether such mental illnesses as schizophrenia can be prevented or effectively treated as a result. But Pauling already has a resounding name for his brain child: "orthomolecular psychiatry," or giving the brain the right molecules in th e right amounts. Chromosome patterns or " karyotypes" are usually made by taking white blood cells, growing them in the laboratory and dousing them with a weak salt solution. This explodes the cells, separating the chromosomes. These are stained, spread on a slide and photographed. From an enlargement, pairs of chromosomes are laboriously cut out, paperdoll fashion , lined up by size and shape in seven groups, and numbered from one to 22 (the "Denver classification" ) . X and Y are usually placed at the end. -:+ - -Reprint from Tim e, May 3, 1968 NATIONWIDE PHARMACY CENTER in the McKAY-DEE PROFESSIONAL BLDG. at 3905 Harrison Blvd., Ogden, Utah, Telephone [phone] Fine Professional Pharmacy with Complete Home Care Medical Service at Prices You Can Afford, and Free Delivery. Open till 9 p.m. Sale and Rental of Medical Aids for Home Care and Convalescence : Wheel Chairs Hospital Beds Surgical Supplies Orthopedic Garments Traction Equipment Supplies for Colostomies and lleostomies Patient Lifts Walkers, Canes, Crutches Professional Fitting in an Air Conditioned Fitting Room Prescriptions filled by owners : Merrill L. Peterson, R.P.H. Burt J. Tensmeyer, R.P.N. 24 . ---- - ----~~~~~~~~- RENTALS and SALES " Complete Hospital and Medical Supplies" whee l c hairs commodes wa lk aid s Presente Stat£' 1 bird resp irators oxygen hospital beds He Ma ASK FOR FREE CATALOG Cl\~!:!'~~t Bus. 637-2512 Res. 637-3409 Public day will 1 point of ployed b Departmt cxperienc 205 West R. R. AVe. PRICE, UTAH NOTICE Public Employees For Your Information Civil Rights Act 1871 One of the statements some elected officials make to public employees is that they have no right and are subject to dismissal if they organize and attempt collective bargaining. This statement has recently been refuted. The U.S. Court of Appeals in St. Louis ordered a commissioner of the City of North Platte, Nebraska, to reinstate two discharged employees and to pay them damages. The court reaffirmed that the First Amendent which provides freedom of association for any lawful purpose, including promotion of workingmen's interests, protects the public employee and that this protection is extended to the states by the Fourteenth Amendment. Zella B Public He Public H an especi public he, spon ibilit affecting J three ma disco,·erie: developm1 demands would lik1 practice i1 influences The sp1 developm( society is ; Yet the pi prepared 1 to employ fit of her researcher develops a for pheny public hea the person covery me the public cl iseasc am of the test make sure have their weeks of a PKU is de low throu ~ and suppo1 "The plaintiffs sued the commissioner under section 1-1983 of the act of 1871, which imposes liability upon anyone who deprives another person of guarantees under U.S. Constitution and statutes wh ile acting "under color" of law or usage of a State or territory. Specifically, they charged that by firing them, the official deprived them of the freedom of association under the First Amendment, as extended to the States. Upholding the plaintiffs and overruling a district court's opinion that the facts in the case did not constitute a claim under the old law, the appeals court held that the defendant commissioner had, indeed. violated the First Amendment's guarantee by discharging the employees while acting "under color" of law: he exceeded his official authority by invading constitutional rights of the em· ployees." Research ment have on the aw in the are; ticnts used or were rel tients arc n pier lives i public heal the cystic infancy thr expensive, Utah Nurse Summer, 191 -~~~~~~~~~~~~~ - - SALES tat and ies" respirators oxygen wspital beds Public Health Nursing Today Presented by Ruth D eRisi at Utah State Nurses Association Public TALOG Health S ection M eeting mF~l. May 16, 1969 Park City est R.R. Ave. 'RICE, UTAH >ye es 1ation ct 1871 s some elected lie employees right and are they organize e bargaining. ently been re- i\ppeals in St. issioner of the Nebraska, to ;ed employees ges. The court .rst Amendent 1m of associairpose, includ·kingmen's in1blic employee m is extended 1e Fourteenth 1d the commis1on 1-1983 of which imposes yone who deson of guaran)nstitution and tcting "under sage of a State :cifically, they .ring them, the iem of the freeon under the as extended to ding the plainling a district ,at the facts in t constitute a Hd law, the apthat the defen!r had, indeed, Amendment's flarging the emacting "under e exceeded his r by invading hts of the emUtah Nurse Public health nursing as it is to day will be presented from the viewpoint of a public health nurse employed by Salt Lake City Health Department, where the bulk of my experience has been acquired. Zella Bryant, former Chief of the Public Health Nursing, United States Public Health Service, has written an especially good article on the public health nurse's expanding reponsibilities. She divides the factors affecting public nursing practice into three main categories. They are: discoYeries in science and medicine, del'elopment of new resources, and demands of an interested public. I would like to examine our current practice in the light of these outside influences. The speed with which scientific derelopments are taking place in our society is almost too much to grasp. \"ct the public health nurse must be prepared not only to grasp them but to employ them to the general benefit of her patients. For example, a researcher working in the laboratory dcrelops a simple and accurate test or phenylketonuria ( PKU ) . The public health nurse becomes one of the persons who must make this disrorcry meaningful and beneficial to the public. She must describe the disease and explain the importance of the test to her patients. She must make sure infants in her case load hare their second PKU test by six 11ceks of age. In the event a case of PKU is detected, the nurse must folI01r through teaching, encouraging, and supporting the family. Research and scientific development have had an enormous impact on the average life span, especially in the area of chronic disease. Patients used to die at a very early age or were relegated to ins ti tu tions. Patients arc now living longer and happier lives in their own homes. The public health nurse visits and advises the cystic fibrosis patient from infancy through the teen years. The expensive, complicated equipment Summer, 1969 used in caring for the patient is sent home with the patient, and the public health nurse helps him understand and operate it. Patients with kidney disease arc now ' having home dialysis and the shunt operation is performed on the child with hydrocephalus . As each scientific development is put into use by the medical and surgical specialists the public health nurse must learn how to use it skillfully to the benefit of the patient in the home. The second factor Miss Bryant listed was the development of new resources. She was referring to new services and facilities which are becoming available to the public. In this area I would mention, Senior Citizen's Centers, Meals on Wheels, Centers for the Care of Handicapped or Retarded children, Specialized Traveling Clinics, Community Mental Health Centers, and After Care Programs. Today's public health nurse shou ld be familiar with these agencies so that she is prepared to help patients use their services. Development of new resources should also include resources which are established as the result of new legislation. Every nurse in this room has felt the impact of President .Johnson's War on Poverty, the Community Action Program, Headstart, .Job Corps, Operation Boot Strap, and the Volunteer Improvement Program , Suddenly there are many workers, professional and lay, trying to reach and help the patients. The nurse has found it necessary to learn to work with these workers to give them the benefit of her experience in working with the poor. The public health nurse has found these new workers a rich referral source. Other legislation and governmental health plans have provided the public health nurse with new working areas. The Tuberculosis Eradication Program has taken the public hea lth nurse into the schools for yearly skin testing. She is involved in the carefu l follow up of all tuberculosis suspects and contacts, and in the distribution of medications to these patients. The Hill-Burton Act required the states to set up m inimum standards for nursing homes. The public health nurse served initiall y as an inspector, of these homes. But her role has de- \"eloped into that of a consultant the public health nurse is looked upon as a source of help. Medicare presented community nursing services with a whole new area of responsibility. Here again the nurse should be familiar with Title 18, Title 19, vocational rehabilitation and the many services legislation has made available to patients served by these agencies. The final outside influence on Public Health Nursing practice is, the demands of the public as individuals. At present, there is a great emphasis on and awareness of com munity problems. The public health nurse should be conversant in and have opinions about such problems as air and water pollution, civil rights, fluoridation, drug abuse, and the population explosion. At this juncture - I would dare say - the Public Health Nurse is the professional person doing the greatest amount of work in the area of family planning on an individual basis. This rapidly changing technological society has had a great impact on the individual American family. It has been changed from the almost independent, extended family to the society-dependent, nuclear family. The public health nurse must be aware of the problems which arc confronting her patients. These may include mental illness. We frequently find ourselves sitting in the presence of a patient who has deep seated emotional problems. Too often the nurse doesn't feel qualified but she is there and she can't turn her back on someone who is asking for help. The nurse finds herself dealing with the problems of severe mental illness, alcoholism, drug addiction, jm·eni!c delinquency, unwanted pregnancies and discipline problems. The nurse refers the patient to appropriate agencies if she is not qualified to handle a problem. In an effort to meet the needs of the patient more skillfully and with greater understanding the nurse attends workshops and seminars. A readiness to accept change is the public health nurse's greatest asset and she must continue to develop and refine it. In a recent American .Journal of Nursing article. Helen Mussallem described the coming changes succinctly: " Facing nursing of the twenty first century will be longer life and less sickness, bigger populations and less food , larger medical advances far beyond our present conception." 2 That is surely a challenge for the future public hea lth nurse. 25 "Expansion The Scheme" Talk - EvA JEAN LAW President, USNA USNA CONVENTION May 15, 16, 17, 1969 Park City, Utah May I begin by paying tribute to those whom I have been associated with these past two years on the USNA board; the committee chairman, advisory council members of district #2. They are truly a group of achievers .... They are representative of those nurses who, regardless of having responsible, busy positions, find time to devote to their profession. They are enterprising persons with loads of imagination and willing to get in and tackle difficult jobs. They were continually searching for ways to improve the nursing profession. They had and will continue to have the dynamism to accomplish much .... I feel fortunate to have had this experience with them. I am the better person for it. I would also like to mention at this time, in my 24 years of experience in nursing I have never known anyone with such boundless energy, with such dedication and devotion to nursing - with less self or personal interest than our Executive Director -- Corallene. USNA is most fortunate to have her. "Expansion The Scheme of Things" will dwell on those current areas in nursing which I believe should be the focus of our association in the next few years. This may seem to some that we are like an octopus extending ourselves in too many directions to be effective ---- but not so all these socalled tentacles reaching out, are necessary for our very existence. Expansion of knowledge and skills to upgrade present practitioners; expansion in numbers to meet the health needs of our fellowmen in Utah; expansi'On into finding solutions to societal problems because of our responsible citizenship; expansion into the areas of nursing practice with scientific management, professional expertise, and personal commitment. First, Expansion of our knowledge and skills, the very nature of our present economy and the technology of our time demand that we take the time to educate ourselves either formally or informally. Peter F. Drucker, well known economist and management consultant, in his book, Landmarks of Tomorrow, says, adult education is as normal in an educated society as is education of children in a literate society. In an educated society it becomes the mark of individual accomplishment and success for an adult to go back to school for advanced education." In fact, he maintains that, "Society must demand that education be considered a responsibility rather than a right, and as a high responsibility by the highly educated." ( 1) Too often in our ranks we hear, by a small minority, I hope - these lines from an old negro spiritual "What was good enough for Paul and Silas is good enough for me." We are creatures of habit. The more difficult it is, hence the more distasteful it becomes to deviate from our established routine. (2) Are nurses in this particular realm? We have many strides in the last few years - but occasionally our own personal and self-interests may interfere with keeping ourselves informed and updated in the positions we hold. We like to continue to believe what we have been accustomed to accept as true and we may seek every manner of excuse for clinging to these beliefs. We may even try to find support for our own views, but if we are responsible members of our community and of our profession, it is our responsibility to continuously prepare ourselves to meet the nursing health needs of Society. Nursing has made considerable change since its' beginning - new ideas, new philosophies, new procedures have been a part of nursing for years. Now, is certainly no exception. In fact, we are bombarded with scientific and technological knowledge - we cannot afford to be left behind. A large steel company's president says, "Education increases our ability to enjoy more things more - to live more richly - more creatively, and in greater harmony with ourselves, our environment and our fellow111an." Right from our early beginnings in nursing our habits and our thoughts, our ways of looking at things were being molded by circumstances almost beyond our control -the family, our work, our church, the area where we live, the social class we belong to - all had a great effect upon us individually and collectively. Now surrounding us, becoming even a part of our lives is social turmoil. We must be totally aware of such happenings and mold our future so that we can analyze and understand the events that are taking place. We cannot live in a vacuum - racial injustice, the war and threat of more wars, poverty amid plenty, the rape of the country's natural resources for profit, all these things anger the young and the old. ( 3) and we must shape our future as responsible citizens to overcome social injustice. We must expand and help develop equal and fair social controls and balance. Even though we live in a free society, does man have an inalienable or constitutional rights to deceive his fellowmen - to cause harm to unborn generations - to destroy institutions? ( 4) Harlan Cleveland in the Atlantic Magazine for May said some startling things, I quote, "The mood is Anti-Commitment in America problems are still right in front of us and we are committed to tackling them because we have the capacity to act - science and technology keep producing more power to be internationally contained ... at this extra ordinary moment in history we just happen to be the world's strongest economy ,its most durable democracy, its greatest military power and its most creative fount of scientific discovery and technological triumph - withdrawal and anti-commitment cannot be our "thing." Our problem is not whether we will be involved. but how. Our capacity to act comes in a package with the obligation to choose a course of action. ( 5) Many years ago in England there were grave social problems relative to public health , morality, education and enforcement of adequate legislation. All these factors contributed to an enforced awakening of public conscience, a mounting public concern, and widespread social discontent. The medical, technological and social situation was ripe for reform - an aroused public became insistcn t in its demand for remedial action --- then came the industrial revolution. (6) Now again - history seems to be repeating itself. Businessmen, professionals, statesmen, ordinary people all must be aware of this, to understand it and to be able to look after their own interests as best they may. The human race so far has survived all other turmoils and revolutions and usually has emerged better off than before, but those peoples who emerge most advantaged will of course be those who manage their affairs with the most understanding and be adept to the spirit :me! needs of the time. We in nursing cannot shape our future with hardened resistance to that which is new and different - In Lincoln's 26 Utah Nurse ---- - - - - - - -- "Wern words, anew." "1 Anothe1 numbers Utah's va ·future cle1 more nun extended homes if mitment Roosevelt of Phi I: College, ( "That it industry r to assure i but make plans for Nursing r earlier an is one of t totem pol< one huncl We have schools of for action nature of ily respon mitments ) tion of nu ket to fill i11g. With th e needi: The ex1 pered, we faculty. I clone new qualified f involved f to still b( with an a< perience a ing stuclen tional pro Landmark such exist! expensive With "cha allowance~ versi ties r ward to sc preliminar Study of tors" had work educ social wo1 with defin needs to needs in c consider I to the nur Our m still is on render. V\ Summer, 1 racial ineat of more y, the rape resources for anger the rnd we must ,onsible ci tin justice. We evelop equal and balance. , free society, alienable or deceive his harm to undestroy insti- the Atlantic l some startfhe mood is America .n front of U5 to tackling the capacity . technology power to be d ... at this in history we ·orld's strongurable demory power and . of scientific 5ical triumph i-commitment Our problem be involved, to act comes obligation to m. (5) ~ngland there ~!ems relative .ity, education equate legislacontribu ted to ng of public g public consocial disconmological and pe for reform became insisfor remedial the industrial gain - history .tself. Businessatesmen, ordie aware of this, to be able to n tcres ts as best race so far has moils and revhas emerged ire, but those most advanbe those who with the most e adept to the ~e time. We in our future with o that which is In Lincoln's Utah Nurse "We must think and act anew" words, "We must think and act anew." Another area of expansion is in the numbers of nurses needed to fill Utah's vacancies and to meet the ·future demands for care. In reality more nurses should be moving into extended care facilities and nursing homes if we are to meet our commitment to society. Franklin D. Roosevelt Jr. speaking to members of Phi Delta Kappa at Teachers College, Columbia University, said, 'That it is interesting to him that industry plans often decades ahead to assure its supply of raw materials but makes almost no short term plans for its' human resources." (7) Xursing resources studies for Utah earlier and presently indicate Utah is one of the states low down on the totem pole in numbers of nurses per one hundred thousand population. We have increased enrollment in schools of nursing as was suggested for action in Utah. But due to the nature of our women's world ( family responsibilities and home commitments) we need an overproduction of nurses hitting th e labor market to fill the gaps we are encounteri11~. With expanding practice areas rhc need is more acute. The expansion of schools is hampered, we say by lack of qualified faculty. However, what have we done new and different to provide qualified faculty? The length of time mrolved for formal schooling seems to still be the same for the nurse with an adequate background of ex1Jerience as it is for the young nursing student just beginning an educational program. Drucker says in his Landmarks of Tomorrow, that when such exists it thus becomes not only xpC11sive time but wasted time. (8) With "challenging exams" and credit allowances now being offered in uni1ersities perhaps we can look forward to some changes in this area. A preliminary report on the Carnegie Study of the "Education of Educamrs" had this to say about social work education. "Their problems in 10Cial work education have to do <l'ith defining" what a social worker needs to know and how long he needs in order to learn it." We may onsider how close this thinking is to the nursing program. ( 9 ) Our maior focus has been and 'till is on the quality of practice we 1rnder. We need this expansion of Summer, 1969 quality on all fronts, especially with increasing responsibility being shared more and more by nursing as our medical colleagues suffer their shortages - And too, with the knowledge our expertise in nursing is most important. Myra E. Levine views the nurse as the agent who helps the patient adapt to his disease, who changes the environment so that adaption is possible, who provides emotional and physical support until adaptation takes place and bases her care on knowledge. ( 10 ) With better educated nurses emerging from our colleges and universities into practice ,those of us who are employed in management positions must exp eriment with new organizational patterns which will be less structured, less traditional and characterized more by openness of communications. There must be more fluidity and flexibility in our nursing services. A study recently reported by General Electric indicates that by 1975 managers will need to lead rather than boss a new work force that will be younger. Twothirds of the net increase in this force will occur in the 20-34 age group. They will be better educated. One of four employees will have attended college, and for the first time in history the rising army of brainworkers, the technical and professional peo ple will outnumber skilled craftsmen. The report from G .E. says managers will have to pay increased attention to studying the different motivation patterns and work aspirations of these new workers. They are gaining more freedom which comes with mobility college degrees, pensions ,and quality of affluence that abolishes hunger as an instrument of social control. A company will have to make the work gratifying or the new dignitaries coming out of college will go elsewhere. ( 11 ) In the past, health agencies like many other business, allowed or offered recognition, status and rewards, primarily to those who attained managerial opportunities only. Now these same health agencies must provide a structure where professional people (nurses and others ) can be effective, gain pride, status, and fulfillment in a position which is not necessarily risk taking and decision making - but at the same time the agency has to do this without destroying the necessary authority and responsibility of the decision maker. There must be unity of action and the discipline of joint effort and performance. A number of businesses or firms have used the following methods. ( 1) Allow technical and professional personnel to take part in the activities and meetings of their societies. This establishes in the employees mind the company's awareness of his skill and regard for his knowledge. (2) Allow the individual to work on special projects or research - management is aware of the need for a flexible time schedule, (3) Provide facilities and equipment which meet the standards of such employees. ( 4) Eliminate the "warden attitude" as it only irritates, but work out problems in the organization jointly. ( 12 ) I think we see attempts toward this kind of management in health agencies wherever nurse specialists are being employed or at least nursing service administration should work toward such attitudes of management. At the same time on the other side of the coin - nurses, if they are gaining benefits and rights on many sides, must also assume responsibility as professionals. Mrs. Doris England. Director of Nursing Service at the St. Louis Children's Hospital, speaking at a student sponsored conferences drew some examples from hospital nursing service of professional commitment. I would like to quote these: ... you may expect adequate personnel benefits including good salarv , vacation and sick leave retirer~ent and other fringe ben~fits. but .. . you rnust assume the responsibility of not abusing sick leave, of providing your share of the nursing coverage for a 24-hour day, of giving adequate notice when changing jobs. ... You may expect to be provided with good inservice or staff development programs, or opportunities to pursue self-development, but ... you must assume the responsibility of using the new knowledo-e for the improvement of patient care, and of giving at least a year's service due to the time, effort and expense involved in orienting and planning training. ... You may expect to be treated as an individual; to be allowed to initiate change, to participate in changes which affect you, but . . . you must assume the responsibility of making constructive criticism, giving the changes initiated by others your full cooperation, treating other members of the nursing staff - particularly non-professionals - as you would like to be treated. 27 "You may expect" ... . . . You may expect to receive respect and recognition for a job well done, but ... you must assume the responsibility of participating in your professional organization or whatever group sets the stage for your professional recognition." ( 13) The direction ·we need to go is not so clearly outlined. Experimentation and diversification will be the order of the day. We need to look on these tasks as opportunities rather than as problems, as chances for success rather than as threatening risks. Perhaps some of the changes may be so major that a whole new pattern will evolve for the nursing profession. A lot of hard work needs to be done. In closing I would like to quote from the words of David H .Burham, / one of the world's truly great architects: "Make no little plans - they have no magic to stir men's blood and probably themselves will not be realized. Make big plans - aim high and hope and work, remembering that a noble, logical diagram once recorded will never die, but long after we are gone will be a living thing, asserting itself with evergrowing insistency. Remember that our sons and grandsons are going to do things that would stagger us. Let your watchword be order and your b e a c o n beauty." (14) REFERENCE S ( 1) Drucker, Jeter F. Landmarks of Tomorrow , H arper Colophone Books, New York, N.Y. 1965, p. 146-147. (2) Jepson, R.W. "Prejudice," Crucial Issues in Education, 3rd edition, edited by Henry Ehlers and Gordon C. Lee. New York, H olt, R inehart, and Winston, I nc. 1964, p. 23-26. (5 ) Cleveland, Harlan, "The Road Back to Internationalism," The Atlantic May 1969, p. 57. ( 6 ) Pelley, Thelma, Nursing, I ts History, Trends, Philosophy, Ethics and Ethos. 1964, W.B. Saunders Company, Philadelphia and London. p. 35-36. ( 7 ) Editorial, Wall Street journal, Sept. 24, 1968. ( 8) Drucker, Peter F. Landmarks of Tomorrow . Harper Colophon Books, New York, N.Y. 1965. p. 147. (9 ) G lascow, Robert W. "The Un-Educating Society," Careers Today, Fall, 1968. p. 38. ( 10 ) Levine, Myra E. "Adaption and Assessment- A Rationale for Nursing Intervention." American Journal of Nursing, November. 1966. p. 2450. ( 11 ) Sil\'a, Michel , "The Mass Elite," Careers Today, Fall, 1968. p. 110. ( 12 ) Bevans, M. J. "Technical Personnel: Managing this Elite Corps" Administrative Management , November, 1968. p. 21. ( 13 ) England. Mrs. Doris, R.N. "Professionalism ." Pulse on Patient Relations, Vol. 8, 1969, Number 2. Sponsored by the S. M. Edison Chemical Company, I nc. ( 14 ) Burnham. Daniel , "The BackYard," United Business Service, Boston. Mass. edited by Paul Talbot. OUTSTANDING CAREERS with State Health Department, State Hospital, State Training School, and Related Agencies PROFESSIONAL OPPORTUNITIES WITH THE STATE OF UTAH Statewide Merit System Top Salaries and Advancement Excellent Fringe Benefits Exciting Career Positions Model Demonstration Acute Stroke Unit The Stroke Division of the Inter· mountain Regional Medical Program is planning the opening of a fiYe-bed stroke intensive care unit at the University M edical Center in the fall of 1969. This specialized unit will be open to patients with acute stroke syndromes and related neurological diseases for diagnosis. treatment and nursing care. Architectural plans have been drawn with the nurse in mind. The unit is spacious, with glass partition between the patient units and nurses' station for ease in constant obserl'a· tion . The unit will be caroetPd to keep the noise level at a minimum and to provide an esthetically appealing and comfortable environment. There is a need for a model demonstration unit to exemplify up-to· date stroke patient management and nursing care. Exemplary care of the stroke patient has not been as clearh defined as it has in other diseases Therefore. the model demonstration Acute Stroke Unit will be used as,, clinical laboratory in which the com· ponents of optimal care of stroke patients will be scientifically investi· ga ted, defined and taught. The unit will incorporate a total care team approach and will include the services of neurologists, a neurosurgeon. a cardiovascular surgeon. Have You Seen The New 96-Bed Modern PAYSON CITY HOSPITAL? Enjoy a Home-town Spirit with PROGRESSIVE For application and circular, contact: PROFESSIONAL NURSING STATE PERSONNEL OFFICE BETTY COOK, Director of Nursing Phone [phone] State Capitol Salt Lake City, Utah Phone: Payson 465-2535 phychia istered social VI pists, sc therapis counsell1 therapis1 and nur The :C cine and a four-l Medical patient ; The reh vide a for the ~ to achie1 depende1 Nursin will be 2 ing expe with pro1 each pati histories sion inte: for indivi will rece nursmg c of makini various I paramete Familiari1 cepts is < will hav1 nurses mt modern, such as tl pirator, n data colle W e are of the str< tients disc Stroke Irn homes, p home will of observa Referrals partment J health nu tinuing se his family. A two-w in Septeml becoming able in th The cours1 Stroke Pa physiology, diagnostic medical m is on acu pects of nu be held a Center. Fu obtained b IRMP Str Medical D 84112. Summer, 19 stration 1e Unit of the InterMedical Proe opening of nsive care unit ~ ical Center in ~ is specialized patients with es and related for diagnosis. g care. ts have been : in mind. The glass partitions nits and nurses' nstant observabe carPf'tPd to at a minimum 1etically appeal:nvironment. r a model dem~emplify up-to.anagement and lary care of the t been as clearly other diseases. ] demonstration ·ill be used as a which the com~re of stroke patifically investi.ught. orporate a total and will include •logists, a neuro1scular surgeon. phychiatrists, a nurse-specialist, registered nurse, physical therapists, social workers, occupational therapists, social workers, occupational therapists, a vocational rehabilitation counsellor. a psychologist, a speech therapist, licensed practical nurses, and nursing assistants. The Department of Physical Medicine and Rehabilitation will provide a four-bed unit at the University Medical Center to receive the stroke patient as his acute illness resolves . The rehabilitation service will proride a full rehabiliation program for the stroke patient, assisting him to achieve the fullest degree of independence possible. :\Tursing in the Acute Stroke Unit will be a stimulating and challenging experience. We are concerned with providing personalized care for each patient and his family. Nursing histories in conjunction with admission interviews will provide a basis for individualized care. The patients will receive intensive neurological nursing care; nurses will be capable of making astute observations on the mious physical and physiological parameters that will be measured. Familiarity with coronary care concepts is essential since the patients will have cardiac monitors. The nurses must be skilled in the use of modern, sophisticated equipment, such as the new MA-1 volume respirator, monitoring equipment, and data collection equipment. We are concerned with the future of the stroke patients. For those patients discharged directly from the Stroke Intensive Care Unit to their homes, predischarge visits to the home will be made for the purpose of observation and recommendations. Referrals to the Public Health Department for followup care by public health nurses will provide a continuing service to the patient and his family. ern y pirit SING ursing 5 Utah Nurse A two-week course is being offered in September for nurses interested in becoming proficient and knowledgeable in the field of stroke nursing. The course: "Nursing Care of the Stroke Patient," includes anatomy, physiology, pathophysiology of stroke, dia~nostic techniques, methods of medical management, and emphasis is on acute and rehabilitative aspects of nursing care. The course will be held at the University Medical Center. Further information may be obtained by writing to Ida Bickle, IRMP Stroke Division, 50 North }fedical Drive, Salt Lake City, Utah 84112. Summer, 1969 Facing The New Horizon Distinguished Members of the Utah State Nurses' Association and Guests. Speeches usually start with the speaker stating what an honor it is to be asked to address a group. I would like to say that I am proud to be asked to speak to you on the subject for which I still, after 25 years, in the profession, experience a sense of excitement and feeling of enthusiasm. The theme of your convention, "New Horizons," seems very apropos and timely, due to the many changes which are taking place in medical services to patients today. The nursing profession is a colleague of the medical profession and other disciplines. When changes occur, the nursing profession has to take a look at itself, assess and evaluate the functions of nursing and other paramedical personnel. Logically, we cannot have progress without change. The community, government and people are concerned with maximum and efficient health care. Nurses are concerned with how to give efficient care and continuity of care within the scope of their knowledge. The nursing profession today is faced with social and economic problems which influence the care of patients on all services within the hospital. For example: We are experiencing more patients of drug abuse on Maternity and Newborn Nursery and more adolescent suicidal attempts in Medicine, and in Orthopedics. The drug abuse patient in Surgery requires more anesthesia, and nurses are offtimes the first to discover that the patient is an addict. We are experiencing more indigent patients. Let me ask you this question. Do you feel there is a difference in attitude of nurses who give care to patients in private hospitals as compared to nurses who give care in city, county and state agencies? In my opinion it is very thought provoking and there is a difference in attitude. I advocate that all students, medical, nursing or paramedical should have clinical experience under circumstances, so that upon applying for a position with a city, county or state institution, there will be more compassion and more incentive to give quality care to all patients, regardless of social or economic status. Traditionally, nurses have been bogged down with duties from clerical work to housekeeping tasks, and patients were cared for - but how? We have delegated tasks to the practical nurse, the nurse aide, and now on the horizon looms various technicians. What are some of these New Horizons that have appeared on the scene and will come to the scene within the profession in the future? Ward clerks are being utilized heavily in many hospitals. They perform routine clerical work in the nurses' station, answer the telephone, receive and relay messages, and have specific duties assigned concerning the patient's charts, assembling, and keeping Medicare forms and transferring orders from the doctors' order sheets. This classification of personnel re1ieves the nursing personnel from much paper work, and releases the nurse to do more direct or indirect patient care. Basically the u n i t manager is responsible for nonclerical, administrative activities designed to provide services to clinical units. Take for exam pie: housekeeping and ward clerks within a unit. Their basic responsibility is to solve non-nursing environmental problems of their assigned units, and to give direct supervision to clerks and housekeeping personnel assigned in the areas. This position, however, must be planned and implemented slowly with the full understanding of all services with whom the unit manager will coordinate. If we are to say we want to be patient oriented, then we must release our nursing administrative personnel to give guidance, teach, supervise and give direct patient care. If we are to spend an hour or two taking up the time of a head nurse or supervisor to get a leaky faucet repaired, or a hopper unplugged, then we have taken that much time from the nursing care of the patient. It is my personal feeling that the unit manager and the ward clerk save money as well as time and effort, due to the fact the nursing personnel arc released to accomplish what they have been trained to do, and it helps to define their role with the patient. The clinical specialist role is being expanded now, and will be, more and more in the future. The clinical specialists arc experts within particular field in nursing and serve as consultants in the guidance of other nurses to insure quality care of patients. Why should not we, in the nursing profession, have specialization in nursing? This is the age of specialization in all fields. (co ntinued on next page) 29 "Staffing must be flexible" Data processing and computers are here, and hospitals are having surveys and hiring data processing personnel to keep the flow of patient information available and readily accessible for immediate use. I do not feel , however, the robot will ever replace the nurse . Utilization of personnel and staffing have gained great attention, and the momentum of this attention is gaining. Staffing has become so important, and must be flexible to meet the needs of the patients, not the nurses. I feel this has gained importance due to the lack of registered and practical nurses today. How do you utilize people that you have within the health and community agencies to get the most effective service when there are no other personnel available? At our hospital we have attempted to solve this problem with nurses in various positions recommending other nurses whom they feel are interested and concerned, and orienting them in their jobs, though they may have the classification of a head nurse or team nurse. Therefore, the care of patients within the scope of a particular position, does not cease if a nurse resigns or becomes ill. Advanced continuing education is growing, due to a need for more knowledge. That is to say, less general knowledge and more integrated knowledge. The educational facilities of communities and states are assuming and will assume more responsibilities for educating the nonprofessional, as well as profession nursing personnel. The h e a I t h agencies employing nursing personnel and requiring qualified care are now and will, in the future, pay part or full tuition to personnel in the educational facilities available to obtain the quality of care they require for patients. Inservicc is on the increase and certainly should be made available to all of nursing personnel according to the need of the particular health agency, and should be utilized to keep the personnel informed of new techniques which may be developed, or reinforce a skill which they have already acquired. Inservice in our hospital is on all three shifts. This is to aid the personnel after completion of orientation as a means of follow-up and the instructor serves as a resource person. In providing this kind of inscrvice, with all members of thC' nursing team, the personnel have a feeling of belonging 30 "Decer to improve communications at an understanding level. Research in nursing is in an infantile stage, and it is here, at the present time, on the New Horizon. Research will aid in the hypothesis, effects, assessments, Yarious methods, procedures, conclusions and evaluations within the profession which may or may not be utilized. Patient care coordinator is a new position. You might say. however, that a clinical specialist could also serve in this capacity if you arc fortunate enough to have one in your e111ploy111ent. The patient care coordinator is in a position to gin· gu iclancc to the various areas th roughou L the hos pi Lal , by assisting in the planning of nursing care of patients. Our staff is studying the feasibility of having a patient care co0rdinator and is detnmining the qualifications this nurse must have, for it is necessary for her to work in all areas throughout the hospital. The staff is vny enthusiastic and this person should be specifically concerned with aiding in patient care planning and not personnel problems. The community nurse has come into her own for the simple reason we cou ld not possibly build enough hospitals nor acid to the existing agencies to care for all the patients. The community nurse will do much in the way of pre\·ention, teaching and therapy in order to reli eve our inpatient loads. In the current journals there is great concern about the spread of infection within the health agencies. It has been recommended that hospitals have infection committees as well as an infection nurse. Within our hospital, we have a nurse who is known as the infection nurse, and works with the infection committee of the hospital. The position is on a supervisory level and it is her responsibi lity to coordinate proper techniques and methods to implement the policies and programs of the hospital infection committee. She also assists with surveys and helps with nursing care plans on a ll reportable infections. She participates actively as a member of the nursing procedure committee a nd works with inscrvice in instructing a ll new personnel. Let us proceed to talk about the new graduate. The new graduate is insecure as to her acceptance into a health agency when she applies for a position. Do you have any kind of meeting, or tea or coffee, to let them meet the supervisor, the head nurse? Do you talk with them concerning the philosophy of the institution or agency, and the philosophy of the nursing department? It seems to me that if we express concern and interest in these you ng nurses who are on the threshold of their career. that we will reap the benefits mam times over in terms of quality care. Too often, nurses are afraid of the new graduate because they see them as a threat. and they use the weapon of experience against them. Han you ever thought of the other side of the story? You could turn this expe1icncc into a usefu l tool to aid thr new nurse in not making the samr mistakes that you made in yow career. and to guide her and help lwr assess her own Yalut·s in tern11 of patient care. Then. and onh then. will you han· a new graduatt· who will stay, have job satisfaction. and will offer loyalty and stability to tlw institution. This has \\'Orkrd fo1 us in terms of the many schools ol nursing who affiliate in our clinical facilities . There has been an increasl in applicaitons for positions in areas within the hospital in which the stu· dents <i re interested and concern i1 shown them. Therefore. thc1· ha1e the feeling that they will be 'able to ach-ance in the ranks of nursin~ within our institutions. Nurses nml to help nurses for the sun-ival of tlu profession. Decentralization is a subj ect that I am firmly convinced is necessan to gi\"C better results and better utiliza tion of personnel with the end product being quality and efficient care of patients and families. For example: Dissolve some of the hierarchy in the nursing department and the organizational structure to lessen the barriers between the administratiYc nursing staff and the nursing personnel who gi1'C serrice to the patients. If we arc patient oriented. not only must we relinquish control of many nonnursing duties handed to us traditionally. but we must pm thr way for the development of creativity among the staff. Nurses sometimes resent giving up these traditional duties. and yet they complain wllC'n other personnel get too close to the patient. In some hospitals. we have assistants. associates, more assistants and the assistants to the assistants, to go through before you can really find out who is sitting at the top. In our hospital. there were positions such a< house supervisor. who in turn had supervisors who were supervised. This position. as well as some of the Utah Nurse uperv1soP filled on a an interes· \Ve broke lnated the \·isor. \\Te training c and after ccrned. si; the areas i and were Yanced stt Twentyinstituted exhibited I ideas anc buried un organizatic zation wa! and their : ing the \ 'a into consi• searched t were mad new satisf member hi develop h1 in an adm of securit1 able to co own prob guidance< of Nursing In any should be tions of n is institute all nursini them with and this operation the plan a the plan. started ta! they had l really did changed i1 has resul· continuity every om same goal: any new i your inst and your care. Deci better util terms of the hospit sonnel be in these personnel Summer, 1 "Decentralization - institution or ophy of the : seems to me cern and inurses who arc their career. benefits many quality care. afraid of the they see them ·e the weapon them. HaYc ~ other side of 1rn this cxpcr101 to aid the cing the same 1ade in your her and help dues in terms _·n. and only new graduatl' ib satisfaction. md stability to 1as worked for am· schools or in 'our clinical :en an increase sitions in areas which the stumd concern is HT. thev han· "·ill be 'a ble to ks of nursing s. Nurses need survival of the a subject that eel is necessary Its and better el \\·ith the end y and efficient l families. For some of the ing department al structure to tween the aclstaff and the ho gi\·e se1YiCl' c oriented. not uish control of 1tics handed to we must pave lopmcnt of crcff. Nurses someup these traclit they complain I get too close to . we have assis~e assistants and assist<ints, to go can really find the top. In our positions such as ho in turn had 1cre supervised. II as some of the Utah Nurse better utilization" mpervisory positions, was evidently filled on a seniority basis, rather than an interest within the clinical areas. \\'e broke down this barrier and eliminated the position of house superrisor. We found out the interests and training of the various supervisors and after consulting with all concerned. supervisors were placed in the areas in which they had interest, and were going to schools for adranced studies. Twenty-four hour supervision was instituted and these were nurses who exhibited leadership ability, had good ideas and suggestions, but were buried under the hierarchy of the or~anizational structure. Decentralization was discussed with the staff. and their ideas and feelings concerning the \·arious positions were taken into consideration, justified and re•earched before any definite changes were made. This brought about a new satisfaction because each staff member had to review and study and <lel'elop her role. It gave the nurses in an administrative capacity a sense of security and a feeling of being able to cope with and solve their own problems, and also have the ~uidance and support of the Director of ~ursing. In any decentralization, the plans 1hould be explained to all classifications of nursing personnel before it is instituted. We called meetings of all nursing personnel and presented them with the decentralization plan, and this brought about better cooperation because they understand the plan and felt they had a part in the plan. Believe it or not, nurses started talking to nurses with whom they had been working for years and really didn't know. They even exchanged ideas and complaints. This has resulted in twenty-four hour continuity of patient care because every one was involved with the same goals of patient care. However, any new ideas must be applicable to \'Our institution, your department and your requirements for patient arr. Decentralizations has given us better utilization of our personnel in terms of needs and interests within the hospital. Nurses interchange personnel between units which results in these areas being covered with personnel who have had some expeSummer, 1969 rience in the areas, and are therefore giving efficient and qualified care. There were head nurses on all three shifts, and every head nurse on each shift felt she was doing her own thing, resulting in three hospitals rather than one. These head nurses accepted the positions merely for monetary and personal reasons rather than the needs of the patients and the hospital. After meeting with some of the head nurses I discovered that they really didn't want the responsibility. In the decentralization, we eliminated PM and night head nurses positions, and now have only the head nurse position on days. Supervisors who were on PM's and nights were on these particular shifts because they did not want to be in,·olved with all the personnel who were on the day shift. They accepted these positions, putting in their time and collecting a check, not for super,·ision, but for making rounds. \Vhen we started to decentralize at our hospital, it brought out nurses who had been hiding many with good suggestio11s and ideas for improwrnent of patient care within their area. We began recognizing people for their ideas and encouraging them to return for continuing education or to return to school and enhance their capabilities. The team concept is here and is necessary, and decentralization forces personnel to work as a team, not only within their own peer group, but with other disciplines throughout the hospital. It is up to the Director of Nursing and other leaders in administrative nursing positions to recognize the human element of nurses, as well as patients, for we too, are individuals with feelings and emotions and should be treated as such. The supervisors were spending a great deal of time in the supervisor's office and I finally decided to see what they were doing that required so much time. I discovered that the time sheets and many requests for change of days off and leaves of absence - you name it, and they came up with it- were keeping them away from their areas, for great lengths of time. I approached the supervisors in terms of how, they felt about so much time being devoted to such a chore and most of them responded that they would rather be on their areas with the personnel. We came up with a totally new position. We approached administration with this new idea on an experimental basis for three months then evaluate it, and if the idea worked, to institute it in our organizational structure. This position is called nursing personnel coordinator. The position plans and coordinates staffing patterns for the entire hospital, interviews nursing personnel for positions in nursing and coordinates. with the 24-hour coordinators in terms of their needs. This position has eliminated both the supervisor and head nurse from remaking and crossing out time schedules. An organizational plan must be flexible. At our hospital, the organizational plan is based on the oneboss system, due to the fact that when personnel have two and three people to whom they are responsible. there is much lost in the interpretation. By reporting to one boss, there can be less chance of misterpretatio11. In my opinion, it is also an effective way of assigning responsibility, as well as receiving the com1n1mication. It would seem that l have mentioned to you some areas which arc now with us and will be appearing 011 the New Horizon within our profession. It would seem, in discussing some of the things that are taking place within our hospital, that it is an ideal situation. I would like to allay any of your fears and tell you that in any new idea there are always problems which must be resolved, but I am happy to say that we have a staff who feel that they can communicate with each other as well as the Director and we do attempt to resolve the problem so that they are at least workable for all concerned. keeping in mind that it is the patient who comes first. If you believe in yourself as a nurse, know your role and your function. You can then face the New Horizon confidently. I am grateful for the opportunity to share some of the excitement and the challenges the nursing profession is offering all of us, now and in the future. The end product, we hope. will produce effective, quality patient and family care, and as professional nurses, we can face the ew Horii'On with a new look. Thank you. Sf1eech given by Margaret Hardin at U.S.N.A. Convention 31 Must America Go Metric? H arla11d M anch1·st1T Ever since the United States was founded , advocates of the metric system of weights and measures ha,·c been urging its adoption in place of our present unwieldy arrangement of feet, pounds, rods, quarts and bushels. Last July, Congress finally passed legislation authorizing the Bureau of Standards to study the idea. While the Bureau's report cannot be prejudged, many experts believe that the handwriting is already on the wall - and that for us, it spells "metric." If the United States does indeed convert. she will be a latecomer on board the metric bandwagon. Most European countries have used the system of meters, grams and liters for generations .In the last 20 years, the countries of another billion and a half people - about half the world's population ha\'e gone metric. They include Japan, China, India, Egypt and Israel. South Africa, Australia and New Zealand are follow ing: so is Great Britain. This leaves Canada and the United States as the only big countries still clinging to the fading imperial system of feet and pounds, and now Canada too may prepare for conversion. Many American scientists and industrial leaders belic\'c that we cannot continue to stand alone. and that, since our adoption of the meter is inevitable, we will save ourselves time, money and headaches by studying the experience of Britain as she undergoes the throes of conversion. The British announced their support for "metrication," as the conversion is called, in May 1965; they hope to ha\'c it completed by 1975. The change, which will alter the language and affect the th~nking of 55 million people, was not dictated by the government - British industry asked for it. More than 60 percent of all United Kingdom exports now go to countries using the metric system, and many big manufacturing firms have been forced to run duplicate plants using both the imperial and metric systems. Moreover, a confusing mixture of the two systems sometimes appears in the same product. For instance, when a British rolling mill gets an order for steel from the Continent, the customer may accept big parts in inches, but will specify that the nuts and bolts must be in metric sizes. So the British company has to import bolts to fill the order. Result: reduced profits. Guaranteed ... "One Full Year's Membership" U.S.N.A. Adopts " Flexible Membership Year" Inform you r profession al colleagues : -Join U.S.N.A. now, on any day of any month in the current year -A full year's - 365 days privileges are guaranteed membership -Apply now to District Credential Committee for Application -Membership year commences date money and approved application are processed at U.S.N.A. Headquarters -. The voice of membership speaks Scientists and educators have long championed the simplicity and efficiency of the metric system. Before its advent. measurement was based more on whim than on logic. The cubit used by carpenters in Noah's time was the length of a man's forearm from the elbow to the tip of the middle finger. Britain's imperial system is a jerry-built structure based on the units brought in by the Roman conquerors 2000 years ago: it has been propped up and patched many times. Legend has it that King Henry I decreed the yard to be the distance from the point of his nose to the encl of his thumb. Purportedly. the rod was defined as a combined length of the left feet of 16 men lined up to go to Church; an acre as the amount of land a man could plow in a clay; the inch, three barleycorns laid encl to encl. Invention of the decimal point in 1585 by the Flemish mathematician Simon Ste\'in, together with his proposal of a decimal system of measurement, laid the foundation for the metric system. It was not until the French Revolution created an atmosphere of change more than 200 years later, however, that the plan was adopted. In 1791 , 12 member of the French Academy of Sciences were appointed to frame a new decimal system based on the natural world. They defined the meter as one ten-millionth of the distance from the equator to the pole. Until recently, a platinum-iridium bar kept in an air-conditioned vault near Paris served as the world standard meter. Now the meter is based on the wave-length of orange-red light given off by the clement Krypton 86. which can be measured with greater accuracy in scientific laboratorie. throughout the world. An incli If a metric something stance, a g-ram 16 c foot-and-po find conver pcrial long quite so sim tries save co culations. E States estim. save a stude figure drud school. In Britai1 dustry and their own p version. Bril converting t engineering minology . .A students mus in metric syn professional Ii ready has ~ scale - in ' freezing poin boiling point and clinical both the Fa! grade scales < In the fall dustry finishe room metric lu contrast to our cumbersome foot-pound -quart system, which rcq u ires its users either to memorize dozens of conversion figures or to have a reference book handy, thr metric system is a model of clarity. The meter (39.37 inches ) is its foundation. The liter is the volume of a cube one tenth of a meter on each side, and the gram is one thousandth of the weight of a liter of water. Prefix these words with kilo- ( 1000 . centi- (1/100 ) and milli- (1/1000 and you can make all common measurements. A liter of water, for instance, weighs a kilogram. c A Calculating with the system is easy: you merely move the decimal point. 32 Utah Nurse Summer, 1969 rs have long ity and effi·tem. Before t was based logic. The ·s in Noah's man's forcrhe tip of the imperial syscture based ~ by the Roycars ago; it and patched · it that King trd to be the t of his nose Purportedly, a combined : of 16 men rch; an acre a man could three barley- imal point in iathematician with his protem of measfation for the not until the tted an atmo1re than 200 :hat the plan 12 members 1y of Sciences 1e a new decithe natural the meter as the distance 1e pole. Until 1-iridium bar 1ed vault near oriel standard r is based on ange-red light it Krypton 86, d with greater : laboratories Aninch is an inch. - 'a metric ton ( 1000 kilograms) of 0mething costs $160,000, for in:ance, a kilogram costs $160, a ::un 16 cents. The victim of the IOt-and-pound disease would not ind converting the p~ice of an imrial long ton to pnce per ounce uite so simple. Indeed, metric coun1es save countless man-hours in calilations. Educators in the United 'tates estimate that the system would me a student at least six months of ,~urc drudgery in grade and high hool. In Britain, various groups in in.ustry and education have made · 1eir own plans and elates for con•rsion. British publishers arc now onrerting thousands of science and n~ineering textbooks to metric ter1inology. After 1971, engineering :udents must answer exam questions nmetric symbols in order to qualify 1rofessionally. The British press already has adopted the centigrade ale - in which 0° stands for the reezing point of water and ] 00° its oiling point - for weather reports nd clinical thermometers bearing oth the Fahrenheit and the centi;radc scales are now being sold. In the fall of 1967 the building inustry finished a $23,000 four-bed10m metric dwelling in Colchester. with windows, doors, joints and roof timbers manufactured to metric dimensions. The conversion is giving the building industry a golden opportunity to simply its products. Up to now, for instance, windows have been produced in more than 100 sizes, for no good reason. Under the new system, the number is being cut to 25 or less, thus reducing manufacturing and distribution costs. One of the most pressing jobs in the British changeover is the conversion of millions of machines that weigh, measure or package goods and handle coins. All the machines that make boxes and bottles will have to be redesigned. But the British take a dim view of the suggestion that eggs and oysters be sold in tens instead of by the dozen or half-dozen. Tradition aside, they're reluctant to throw away all those plates and containers with 12 depressions in them. Automobile speedometers and highway signs must be changed from miles to kilometers, too. At first. drivers may get nervous when the needle touches 100 or a sign reads "Birmingham 200 Km"; they'll have to translate to 62 miles per hour" and "124 mi les." But as those who ha\·e driven on the Continent know , ATTENTION REGISTERED NURSES A SPECIAL INTENSIVE CARE NURSING · cumbersome which reto memorize figures or to >k handy, the >de! of clarity. es) is its founvolume of a Eeter on each ne thousandth r .iter of water. hkilo- ( 1000). 1illi- ( 1/ 1000) common measwater, for inam. SIXTEEN-WEEK COURSE BEGINS AT !ID, ~~d~~ IN SEPTEMBER APPLICATION DEADLINE AUGUST 15, 1969 WRITE TO: Intensive Care Instructor Latter-day Saints Hospital 325 Eighth Avenue Salt Lake City, Utah 84103 ~system is easy; decimal point. Utah Nurse However ... the mental shift to meters soon becomes almost automatic. Industry and science arc far ahead of the retail trade in making the change, but, say the conversion specialists, the public must not be "schizophrenic." People must "think metric" on their jobs and then come home and "shop metric,'' too. In the United States, Congress' recent decision to open the doors to discussion follows a long history of "metric controversy." Thomas Jefferson, George Washington and John Quincy Adams all proposed adopting a decimal system of weights and measures. Later advocates included Thomas Edison, George Westinghouse, Henry Ford, Alexander Graham Bell and hundreds of scientists and educators. Congressional and public apathy blocked their plans, but in 1866 Congress did pass a bill legalizing the use of the metric systems for those who wanted to sell goods by the liter, Kilogram or meter. We are thus in the curious situation of having a legal metric system we don't use, while we use afoot-pound system that has never been legalized. In a poll conducted early this year by Industrial Research magazine, 94 per cent of the '.ll 00 scientists and engineers who responded favored the change. The Ford Motor Co. has begun thinking about conversion. Says H. L. Misch , Ford's vice president of engineering: '·The benefits of a single measuring system in a worldwide interdependent economy appear to be so great that we believe con\'Crsion to the metric system is incvi tablc." But big firms arc justifiably concerned with the expense of conversion. General Electric estimates that it would cost them $200 million to go metric. A study made by the Stanford Research Institute estimates the total U. S. cost, spread o\·er many years, at $11 billion. But as Sen. Claiborne Pell of Rhode Island. who introduced the study bill in the Senate, has pointed out, not changing costs us an estimated $10 billion to $25 billion in foreign trade ever)' year. Other metric adherents say that our every year's delay in going metric will boost the cost by about seven per cent. Nobel Prizewinner Harold C. Urey says, "Our use of the English System is Russia's secret weapon." Whatever the facts it will cost us nothing to study Britain's example. -The Reader's Digest October, 1968 33 :Jmmer, 1969 - ~------- Meet Mr. Pepper by: Dr. H. C. Thuline, Research Director and Director of Laboratories, Rainier School Buckle)•, Washingotn 98321 SIGN!FlC/\NCF. OF THIS RESEARCH TO HUMANS Mongolism occurs in 1 of every 600 human newborns. Trisomy D occurs in 1 of 14,500 human newborns. Trisomy E occurs in 1 of 4,500 human newsborns. XXX syndrome occurs in I of 800 girls. Turner's syndrome occurs in 1 of 2,500 girls. Klinefelters syndrome occurs in I of 400 boys. The a\'cragc person, cn:n the average cat owner, probably would not notice anything spectacular about Mr. Pepper. You might think you could walk clown a dozen dark ~lleys and catch glimpses of a dozen tri-colorcd ( black. white and orange ) male cats. You would be wrong. Mr. Pepper, a male calico cat. theoretically shou ldn · t exist. But he oocs, and we should be thankfu l that he docs. He and the few like him may one day lead us to a broader understanding of one cause of mental rctarcla tion, the most handicapping of all childhood disorders. This possibility is being explored by Dr. H. C. Thuline. director of laboratories. and Dr. Darwin E. Norby, geneticist, at Rainer School (the state's largest institution for the handicapped ) in Buckley, Washington. " We think that the same factor that causes a male calico cat may cause Mongolism in human babies," Dr. Thuline explained. "Of course, this does not mean that male calico cats arc Mongoloid. We arc studying the basic cell biology in cats for the factors in cell division that could be responsible for any of the abnormali tics in the number of chromosomes. \Ve arc looking for the common denominators." A farm magazine once stated flatly that "'tom cats don't come in calico." When they, scientists have found the phenomenon related to a chro111oso1nal abnormality. Let's take a moment to u 11dt:rsta11d why a male calico cat shouldn't exist. Each cell of every living thing carries sc\-eral chromosome pairs. Cats han· 19. you have 23. corn has I 0. In animals. one pair decides whether offspring will be male or female. A female cat carries a pair of chromosomes which arc designated XY, and Y is quite different from the X in size. Now, the reproductive cell is only half a regular complement of chromosomes so the female egg can ha\·c only an X while the male sperm can have either an X or Y. If the male sperm carrying X fertilizes the egg, offspring A PATIENT is a person who brings us his suffering and it is our job to heal or comfort him according to his necessities. HOLY CROSS HOSPITAL Salt Lake City, Utah 34 will have an XX sex determining pair and be a female. If it's the Ycarrying sperm that fertilizes, then offspring will be XY and be a ma!e. Only the X chromosome carries genes that determine orange and black color in cats ( they are apparently the only animals with this coat color inheritance situation). The X chromosome can carry only a genr for orange or a gene for black . not both simultaneously. When a cross results in a female with the gene for black on both X chroma- • somes, she is black; if both carry orange, she is orange. But if one X carries black and the other carries orange. she will be a calico. Because male cats normally have only one X chromosome, they can have either a gene for black 01· for yellow (not both ) and shou ld never be calicocoatcd unless something is amiss. Drs. Thuline and Norby were the first to cliscowr that male calico cats ha\" c chromosomal abnormalities. most often an XXY pattern. The two XX chromosomes allow the calico co loring and the Y determines maleness. (Male calico cats arc generally infertile, as are humans with the same type of chromosomal disorder. ) [n addition to this chromosomal variation (XXY ) , Drs. Thulinc and Norby have studied male calico cats exhibiting three other yariations. There has been a fifth type of anomaly described by another worker. "Our most important demonstration," Dr. Thulinc said, "is that there is an animal for research in chromosomal disorders. The cat, in its natural unmanipulated state, spontaneously suffers chromosomal diseases (or abnormalities ) as do people. The most common human chromosomal disorder, easily recognized, is that found in children with Mongolism. "The theories developed by doctors working with human chromosomal disorders can be tested in cats and there is the possibility that a variety of disorders could be experimentally induced." We are fortunate that the distinctive coat color inheritance in cats make the XXY chromosome abnormality identifiable by sight rather than by expensive laboratory procedures since it has made possible these advances in the study of such a common kind of human disorder. From these studies there arise a veq real hope for solving some of the biologic systery that still hides the causes of chromosomal disorders. This article is reprinted from Spring, 1968, Perspective, with kind permission of Dr. H . C. Thuline. Utah Nurse For Qui or answers, marking. y, your care t< marked Qu 1. Streptorr I. a bac 2. an a1 3. an a1 4. a dit 5. a der 2. Digitalis a. incre b. aboli c. stimu d. 1ncre c. stimu 1. a 2. a 3. b, 4. a 5. A 3. The low a. is the b. is to tissu1 c. is pn d. !s pr c. IS pri 1. b 2. b 3. a ·L Fcosal i! 1. for a 2. as ar 3. as a 4. as an 5. as ar 5. Sodium 1. for a 2. as a1 3. as a 4. as ar 5. as ar 6. Hypoth) 1. myx1 2. diab1 3. ere ti 4. acro1 5. ad di: 7. Hypo th) 1. myx< 2. diab1 3. ere ti 4. acrOJ 5. addi 8. Pu Imorn 111 whicl a. the I b. the fillec c. the and d. the e. the 1 1. 2. 3. 4. 5. 9. Diabete: disturba 1. adre 2. th yr• 3. pane Correct ALL TRU Summer, 191 3. a and e 4. all of these 5. none of these QUIZ No. 7, GENERAL REVIEW determining fit's the Y·tilizes, then l be a male. omc carries orange and r are apparith this coat )n). The X on ly a gene r black . . . y. When a le with the X chromoboth carry ut if one X ither carries ico. Because only one X 1ave either a yellow (not r be calicoing is amiss. .by were the le calico cats ~normali tics, iattern. The allow the ~ determines cats arc gcn~ umans with nosomal dishis chromo' Drs. Thu;tucl iccl male three other been a fifth ibecl by an- t clemonstra"is that there h in chromoat, in its naate, spontan1mal diseases 1 people. The chromosomal ized, is that Mongolism. ed by doctors chromosomal in cats and ~at a variety l'perimen tally .t the distincance in cats osome abnorsight rather oratory pronade possible study of such an disorder. e arise a very some of the ill hides the disorders. orinted from ve, with kind Thu line. Utah Nurse For Quiz No. 7, we suggest you circle the number of the correct answer or answers, tear the sheet out and return it to U.S. .A. Headquarters for marking. You will not be graded on this test, but we believe you will improve rnur care tc;i pa.tients if you arc aware of your own gaps in knowledge. Your marked Quiz will be promptly returned for your own use. 4. parathyroids 5 . gonads I. Streptomycin is given as I. a bacteriacidal 2. 3. 4. 5. an antipyretic an antibiotic a diuretic a depressant 10. 2. Digitalis will a. increase contraction of heart b. abolish irregularities of the heart c. stimu late the vagus nerve d. increase the tonus of the heart c. stimulate tht aorta I. a, b, c, and d 2. a, b, and c 3. b, c, and d 4. a, c, and d 5. All of these :l. The low sodium diet a. is the same as a salt free diet b. is to prevent sodium retention in tissues r. is prepared with dialyzed milk d. is prepared with Lonalac c. is prepared with instant coffee I. b, c, and d 2. b, d, and e 3. a, d, and e -1. Fcosal is given I. for anemia 2. as an analgesic 3. as a sedative +. as an antipyretic 5. as an emetic 5. Sodium Salicylatc is given 1. for anemia 2. as an analgestic 3. as a sedative 4. as an antiseptic 5. as an emetic 6. Hypothyroidism in children results in I. myxedema 2. diabetes insipidus 3. cretinism 4. acromegaly 5. addison's disease '· Hypothyroidism in adults results in I. myxedema 2. diabetes insipidus 3. cretinism 4. acromegaly 5. addison's disease Pulmonary emphysema is a condition in which a. the bronchioles become dilated b. the alveoli of the lungs become filled with fluid c. the alveoli lose their elasticity and become distended d. the alveoli collapse e. the bronchi collapse I. a and b 2. a, c, and d 3. b, c, and e 4. none of these 5. b and c Diabetes mellitus is attributed to a disturbance of the I. adrenals 2. thyroid 3. pancreas I I. Diabetes mellitus a. is hereditary b. is more prevalent among J ew c. is on the increase d. is more common in women c. bears some relationship to obscity I. all of these 2. none of these 3. all except b 4. all except c 5. all except a Symptoms to note m diabetic coma arc a. clouding of the scnsorium b. acetone odor to brca th c. thirst d. hardened eyeballs c. cold and clammy I. a, b, c, and d 2. all of these 3. a, b, and c 4. b, c, and e 5. a and b of a. b. c. ti. c. f. g. h. diabetes are glycosuria polydipsia constipation polyphagia loss of weight skin infection cataract backache 1. all of these 2. all except h 3. all except c 4. all except c and h 5. all except e 13. The diagnosis of diabetes principally on findings of a. high blood sugar b. sugar in urine c. glu cose tolerance test cl. X-ray e. gangrene 1. a and b 2. a, c, and d 3. a only 4. a, b, c and d 5. b only IS based 14. Reaction to insulin manifests itself in the following ways a. nervousness b. hot, dry skin c. faintness d. hunger c. tremors 1. all of these 2. all except b 3. all except e 4. all except c 5. all exctpt a 15. Symptoms of atelectasis are a. severe dyspnea b. cyanosis c. prostration cl. pain in the chest e . high temperature I. a, c, and d 2. a, b, c, and d QUIZ No. 6 ANSWERS Prognosis of cerebral accident depends on a. progress of paralysis b. immediate nursing care c. extent of hemorrhage cl. improvement of muscular power c. extent of paralysis 1. all of these 2. all except c 3. all except d 4. all except e 5. none of these I 7. Tachycardia is I. high blood pressure 2. low blood pressure 3. rapid pulse +. slow pulse 5. low pulse pressure I B. A subdural hematoma is caused by I. arterial bleeding 2. venous bleeding :t bleeding into the ccrebrospinal fluid +. edema of the brain I 9. Cystitis is I. an infection of a cyst 2. the development of a cyst '.{. an infection of the bladder 'L an infection of the kidneys 5. an infection of urethra 20. In congenital dislocation of the hip the I. shaft of the femur is deformed 2 . epiphysis of the femur is deformed 3. pelvis is narrow 4. pelvis is wide 5 . acetabulum is shallow I '> Symptoms which may be suggestive Correct answers to Quiz No. 6. Utah Nurse, Spring, 1969 page 43, are: \LL TRUE. Summer, 1969 16. 2 I. Chi ld ren with cerebral palsy l. usually are mentally deficient 2. usually are mentally superior 3. may have normal intelligence 4 . cannot learn 5 . learn rapidly 22. Rod-shaped bacteria are called I. bacilli 2. cocci 3. diplococci 4. measles 5 . malaria 23. In the female. cancer appears most frequently in I. uterus 2 . breast 3. ureters 4. ovary 24. The scientist who discovered radium IS 1. 2. 3. 4. Roentgen Curie Ascheim Fowler 25. Arteriosclerosis a lters normal physiology and structure by a. reduction of elasticity of the arterial walls b. less effecti,·e vasomotor regulation c. involvement of the external coat of the arteries d. predisposing to rupture and hemorrhage e. lowering the blood pressure I. all except e 2. all except b 3. a, b, and d 4. all but c 5. all of these 35 ADDRESS CORRECTION REQUESTED BULK RATE Retmn Postage Guaranteed Utah State Nurses' Ass'n. 42 So. 5th East Salt Lake City, Utah 84102 U. S. POST AGE 101'-:~i-brar~, ·Un!:Y-ersd'.lly- :oVUtah.P A ~ .D . · , I> . . s.;Ji Lake Cit~" Utah Univ er-Sit~ · (;!l"!'lf p~s lJ .. oj U. Permit Na. 1882 Salt · La·~e City.• .. Ut.ab There she vvos. With bright watchful eyes that said "/ con help. A crisp yet gracious bustle of activity 11 The assurance of ski II and reassurance born of genuine concern. A kind and comforting word A sincere smile. A Nurse. BLUE CROSS - BLUE SHIELD -·-- __. Constant attention to the well-being of the patient .. . the mark of a professional nurse in administering care . .. the function of Blue Cross an d Blue Shield in providing for the economics of t hat care .