By Gertrude E. Hodgman, Assistant Professor of Nursing,
Yale School of Nursing, and Katharine Tucker,
General Director, Visiting Nurse Soeiety,
Philadelphia, Penn.

1. Development of the Program. Since the Health Survey of New Haven in 1917, much has happened in the development of public health work. Among the most striking of these developments has been the steady growth of public health nursing. New Haven has shown itself a leader in this field. In 1917 the ratio of public health nurses to the population was approximately 1-5,000; in

1927, 1-2,450, while in 1928 this will be increased to 1 to every 2,216 of population. Looking toward the generally accepted standard goal of 1 nurse to every 2,000 population; it will be necessary for New Haven to increase the number of nurses yearly (based on the normal increase in population to be expected) at the rate of 3 each year for the next 5 years.

It is to be hoped that the City Health Department will be able to continue to assume an increasing proportion of the financial responsibility for this increased service, as methods of maintaining standards of work in public health nursing can be developed and newer aspects of the work proven.

Along with this steady growth in numbers there seems also to have been, on the part of those responsible for developing the services, exceptional appreciation of the importance of high standards of work, and of policies of administration in accordance with the best thought along these lines.

At the time of the 1917 survey, no supervision was provided for the nurses in the schools, there were no nurses doing follow-up work in the Bureau of Communicable Diseases, the tuberculosis work was done by a group of five nurses without specialized supervision, and the infant welfare work was carried on jointly by the Infant Welfare Society and the Visiting Nurse Association, without specialized staffs.

In 1927 there were 13 nurses in the schools working under the supervision of a nurse director of the Bureau of Nursing of the Health Department; there were 4 nurses in the Bureau of Communicable Disease Control; 1 nurse (and 1 male attendant) in the Division of Venereal Diseases; 4 welfare nurses in the Bureau of Nursing of the Health Department doing prenatal and child welfare work, and an average of 55 nurses in the Visiting Nurse Association carrying a broad general program with specialized supervision in the Tuberculosis, Child Hygiene and Maternity services.

In 1920 to 1923 a careful study of the value of a specialized nursing program was made through the opportunity afforded by the "New Haven Health Center Demonstration ". This demonstration was a cooperative program carried by the chief public and private health agencies of New Haven. The study indicated so definitely the value of the general nurse in the home, that since that time the accepted policy in the development of the work has been constantly in this direction. In 1927, the city Department of Health, recognizing the importance of generalized nursing service in the home, delegated its tuberculosis nursing service to the Visiting Nurse Association while continuing to recognize its financial responsibility for this work (to the amount of $1,775.00). For the coming year, 1928, the department is pledged to the amount of $400 a month (4 nurses at $100). This policy of the Department of Health seems to us a very forward looking one.

2. Nursing in the Health Department.
Bureau of Communicable Disease Control. The four nurses of this department work under Dr. Lewis. They visit as far as possible every reported case of measles, whooping cough, mumps, chickenpox, diphtheria, typhoid, (and others as indicated) to placard the house and to remove the placard, and to ascertain the patient's condition and whether he is under medical attention, to secure the observation of isolation precautions, to obtain cultures where indicated, and to follow up contacts and undiagnosed cases, and to release from quarantine.

Also, school absentees of three days and over are investigated by this department as a part of the program of communicable disease control. Statistics of the nursing work are as follows: Total visits 22,859; school absentees 7,747.

There seems an opportunity for avoidance of duplication and for better correlation between the work of these nurses in the home visiting of school children and the regular work of the school nurses under Miss Barrett. We would urge that this question be given careful consideration by the Department.

This department also maintains the services of a practical nurse or housekeeper who is used to care for mild cases of communicable disease in the home, thereby enabling the mother to continue her work if she is the bread winner for the family.

The Division of Venereal Diseases. The greater part of the time of the nurse is engaged in attendance at clinics. Home visits are made to clinic delinquents, and occasionally to find contacts. The greater part of the latter work, however, is done through patients already in attendance at clinics, since it is usually considered not advisable to visit contacts without the permission and knowledge of the infected person.

At present there is no means provided of informing other nursing agencies concerning cases of infection of these types in the home. Since both the school and Visiting Nurse Association nurses are constantly visiting in homes where some member of the family is under treatment in their clinic and where such information might be of great service in obtaining information as to diagnosis and treatment of contact cases, it would seem that some plan could be worked out between these groups which would stimulate the finding of more cases without undue publicity concerning the infected person.

Bureau of Nursing. The nurses of this Bureau under Miss Barrett's able direction and supervision, are divided into two groups, school nurses and welfare nurses. The school nurses carry on the usual activities of school nurses in relation to the first aid care of minor ailments, re-admission to school after three day absences, (except cases of major contagion) assistance with physical examinations of first and third grades, (also of newcomers, in second and fourth), class room inspections and health talks and home visits.

Qualifications. The nurses are employed under civil service, which requires that they be graduate registered nurses under 40 years of age. Appointments are made according to standing in the examinations. It would be highly desirable to work towards the requirement of a high school diploma as a prerequisite to appointment.

Salary. The salary scale is from $1,200 to $1,550 for 12 months (one month's vacation). Increases are granted at the rate of $50 each year.

Program. The program in school nursing includes the grade schools, public and parochial, and two Junior High Schools; including about 28,600 children, of whom about 4,000 are in parochial schools. This is an average of 1 nurse to 2,200 children. Each nurse works in 4 or 5 schools. During the summer months home follow-up, vaccinations, Schick testing, etc., are carried on.

In February 1928 two nurses were added to this staff,- a total of 15. Two Junior High Schools were added. The ratio of nurses is now 1 to 2,000 pupils.

Educational Program. Other than the weekly conference, there is no definite program of staff education for these nurses. The Director of the Bureau has many administrative duties in arranging the time of nurses, dental hygienists and school physicians in the different schools. She carries much of the work involved in arranging for clinic appointments for school children and for necessary cooperative arrangements betvveen the other nursing and social agencies and the school nurses. This leaves her very little time for supervision in the schools and for the development of a more effective program in general. Many of the nurses, on their own initiative and with the Director's encouragement, have taken various courses related to their work and in other ways are keeping abreast of their field. The department itself, on the other hand, seems not to have sufficient supervision, nor incentive through adjustment for time and increase in salary, to stimulate the staff to further preparation for the work in their highly specialized and important field.

Welfare Nurses. The program of work of the welfare nurses (3 in 1927, 4 in 1928) consists in the delivery of certificates to newborn babies (2,630 in 1926); referring babies to welfare stations (720 in 1926); social service calls (720); practical demonstrations (only 155, or 51 per nurse); the finding of sick babies (25) and of prenatal cases (79). Also, these nurses supervise the 26 registered midwives of the city visiting each one once each month.

While the work of the welfare nurses is excellent, there is unavoidable duplication involved in the visiting of infants in the homes by two groups of nurses (those of the Health Department and the Visiting Nurse Association). The work performed by the welfare nurses is necessarily very limited in amount since they only pay on the average 2.5 visits per infant and the fact that they have no expert supervision from an infant welfare specialist cannot fail to militate against the quality of their service. It has been proven again and again that generalized service is most economical and efficient and we have here, not only a violation of the principle of generalization but a direct duplication of visitation by two nurses for essentially the same purpose. The delivery of birth certificates, which is of course of great educational value, could be carried on by the staff nurses of the Visiting Nurse Association as the agents of the Health Department in such a way as to effect the most vital contact with the conferences of the Visiting Nurse Association which it is desired that the mothers should attend. The fact that the Visiting Nurse Association nurses are carrying a broad generalized program and are already visiting in the majority of these homes to give post-natal care offers obvious opportunities for economy of effort. The supervision of midwives is a regulatory, not a home nursing, function and there would be no advantage in principle in handling it otherwise than as at present.

In general, however, it would be of advantage from the standpoint of the health program as a whole if the Board of Health would follow the policy adopted in relation to tuberculosis by turning over its welfare nursing to the Visiting Nurse Association and delegating that organization to represent it in that field also. The money appropriated by the city for welfare nurses would bring in far larger returns to the community if expended in cooperation with the Visiting Nurse Association than under the present plan. The Health Department must and should exercise ultimate control of all health policies; but when, at a given moment, better results may be secured at lower costs by cooperating with an existing private agency it would seem unwise not to take advantage of that fact. We have seen, for example, how greatly the city profits by using the contagious pavilion of the New Haven Hospital instead of operating its own Isolation Hospital; and this is another case in point.

3. The Visiting Nurse Association. The Visiting Nurse Association of New Haven has many interesting and splendid achievements to its credit. It is significant that the nurse, Miss Mary Grace Hills, who first came to the Association for a trial period of six months in 1904 is still with the organization as its superintendent and the first president of the Association, Miss Prudden, only resigned her post in January, 1928. These facts, accompanied as they are by the facts of the remarkable growth of this work in numbers and in quality of service, means that the New Haven Visiting Nurse Association has enjoyed, in this age of change, the benefit of a consistent policy and of seasoned experience.

Staff. The nursing staff of this organization for 1927 averaged 55 - this included the Superintendent and Assistant Superintendent, 3 general division supervisors, one supervisor of tuberculosis work, one supervisor of child welfare, one educationa1 director, and a staff of nurses averaging 47 throughout the year. This number included 4 nurses who work in West Haven. With the recent additions to the staff for hourly nursing and delivery service, a total of 62 nurses are at present employed. The ratio of supervisors to staff nurses is 1 to 5.5, an excellent showing and largely responsible for the high quality of work performed.

Budget. The budget for 1927 was $137,000, of which $66,327 came from the Community Chest, $5,000 from the city, $1,775 from the Department of Health, and the remainder from endowment, fees from patients, Life Insurance companies, and from the Employees Tuberculosis Relief Association. Forty-four and seven-tenths per cent of the services rendered were paid for; 6.6 per cent were given free; 48.7 per cent were on a "no charge" basis.

Board. The Board of Directors of the Association consists of 40 members who are all women except for Dr. Rice, the Health Officer, who has been recently elected to this Board; there is also an advisory board of 4 men; and a medical advisory board of 5 members appointed by the New Haven Medical Association.

The Board and its committees present a most exceptional picture of activity and intelligent direction. Each member of the Board is kept constantly in touch with the work and each committee is thoroughly responsible for its phase of the program. Such direct participation, by a widely representative group from the community in public health nursing activity ensures the highest standard of work and continuity in its excellence.

Committees. There are 10 standing committees, with no power to act except the nurses committee, which acts under special conditions. Their respective functions are indicated below:

Nurses' Committee, 12 members including chairmen of other committees and six additional members has to do with policies related to the nurses, salaries, appointments, sick leaves. It acts as an Executive Committee in relation to the Board.

Finance Committee, duties usual for such a committee.

Child Welfare, development and problems of child welfare program.

Tuberculosis, development and problems of the tuberculosis program.

Service and Uniform, really a subcommittee of the nurses' committee relating to sick nurses and problems of uniforms.

Supply and House, duties usual for such a committee.

Home Economics, development and problems of home economics department.

Education and Publicity, responsible for annual meetings (these are open meetings to which the public is invited -a splendid feature of the organization), reports, record department, educational work, printing, publicity. This committee was responsible for the Board Members Institute of 1927, the first institute of its kind in the country, attended with great success. It also arranged at an earlier date an Institute for Supervisors, a real contribution to this aspect of the work.

West Haven. Special problems of West Haven; members are residents of that town.

Volunteer Service. A group of ten women give volunteer service in connection with the work of the record office, and thirteen others assist in the child welfare conferences. Others provide service in the making of surgical dressings and in driving automobiles. Al1 of these activities lend themselves well to volunteer service,-and make an important economic contribution to the work of the organization.

Program. The following data indicate the volume and scope of work of the organization:

PATIENTS AND VISITS.

ANALYSIS BY AGE GROUPS OF CASES ADMITTED.

In the statistical report of "Principal Diseases and Conditions of Patients for 1926" the volume of work in each service can be studied. It is interesting to note that in this organization there seems to be no sacrifice of the educational work in child welfare, prenatal, and tuberculosis work to the needs of the acute and sick services. This is an important point to be considered in any generalized program.

Children's Service in 1926. 3396 cases admitted, which was 43.85 per cent of all admitted cases, with a total of 93,992 visits¹. Thirty-six and seventy-four hundredths per cent of these cases admitted were under 1 year of age. Fourteen well baby and 9 preschool conferences were held weekly, where instructions were given by the 23 conference doctors, nurses and nutrition workers employed by the organization.

¹ It should be remembered that these figures represent total visits paid to a given group of discharged cases often extending back over more than one year.

Maternity Service. The next largest service is ir maternity work, including prenatal visits, - 16.76 per cent of admissions, 11,026 visits, of which 8.34 per cent were prenatal cases. Two prenatal clinics are held each week. Three nurses have recently been added to the staff to provide for a delivery service in the home. The inclusion of this work practically rounds out the program for an adequate community maternity service. Except for the prenatal and delivery cases carried by the New Haven Dispensary and the relatively few cases visited by the welfare nurses of the Department of Health, all the maternity program in its home nursing aspects is provided for the city by this Association. The Junior League offers invaluable assistance in the conduct of the prenatal and the infant welfare clinics.

Acute Service.The third largest service which the Association renders is to acutely ill cases. This amounts to 23.86 per cent of cases admitted, 8801 visits. All cases of communicable diseases except smallpox are included in this work.

Chronic Cases.The fourth service is for chronic cases; 14.94 per cent of admissions, 25,607 visits. Included in this group is the work with the diagnosed cases of tuberculosis; 2.91 percent of admission, 6,870 visits, and with tuberculosis contacts 4.74 per cent of admission, 11,505 visits. To cases of chronic illness (cancer, rheumatism, apoplexy, heart disease, senility, etc.), 7232 visits were made by the organizations during the year, with an average of 15.4 visits to eaeh case.

Statistical Data. The cost of a visit is $1.01. This compares favorably with work in other cities in so far as such comparison is possible.

Hourly Service. On November 1, 1927 the Visiting Nurse Association took over the hourly nursing service which had been started ten months previously by the Nurses Registry.

In spite of the fact that this service had grown for a time it had been on the whole operated at a loss to the registry; and after careful consideration it seemed best to have it carried by the Visiting Nurse Association. One additional nurse was added to the staff as a first call nurse, although several other members of the staff are enlisted in the work as needed to meet calls occurring at the same time. It is expected that this service will be on an entirely self-supporting basis. The charges for this service are $1.50 for the first hour and $1.00 for each additional hour, with a maximum period of four hours.

To date the calls and income for this service are as follows:

In January this ammounted to something more than the time of one nurse.

Mental Hygiene. At the present time the Association has no specialist or supervisor in this phase of work. There is close cooperation between the nurses of the Association and the Mental Clinic at the New Haven Dispensary and Miss Thatcher, the social worker of the Society for Mental Hygiene attached to this clinic.

Orthopedics. This phase of work has not been developed in the Visiting Nurse Association although it is the only organization at the present time available to the orthopedists of the community aside from those directly affiliated with the Crippled Children's Aid Society.

Educational Program. An educational director is employed who is in charge of the various staff educational activities of the association.

Student Nurses. All members of the senior group at the Yale School of Nursing receive a carefully planned course of two months' experience and instruction in public health nursing with the organization. The number of students of course varies with the size of the class. In 1927 there were 9. For this educational work the Yale School pays a portion of the salary of the instructor.

In 1927 St. Raphael's Hospital and the William Backus Hospital, Norwich, each sent 2 students to receive the same two months unit.

Staff. All new nurses who have had no experience in this type of work receive practically the same instruction as that given the undergraduate students. This, however, is sometimes extended for a second two months period, and longer if necessary for the individual nurse. Six months is considered the "probationary" period. Besides this initial educational instruction of staff members, staff conferences are held weekly, which have definite programs planned with the idea of continuing the educational program for both the newer and older nurses. Round tables both with general and with specialized supervisors also play an important part in the educational program. One of the most valuable policies of the organization along this line is that of sending the nurses to conventions and meetings and of giving them opportunity to obtain special instruction which keeps them in touch with new developments in the field of public health nursing.

Records. The statistical department of the organization is well equipped and staffed by six workers, under a registrar. Complete statistical data are kept of morbidity rates in relation to the services rendered. These data seem to us to meet the various needs for use in comparison with the work in other cities, in relation to the activities of the city Health Department and for comparison over a period of years.

Salaries. Staff. The salaries paid to staff members are as follows: $100 for first six months, or until accepted as a staff member; $110, second six months; $115, second year; $120, third year; $125, fourth year, maximum.

In considering a salary scale it is necessary to compare it with other salaries in the same and other communities, to costs of living and to the possibility of an adequate supply. In spite of the fact that data for other cities have been collected for 1926 it is exceedingly difficult to make any fair comparison since it is not possible to gauge the relative advantages offered in the way of educational opportunities, sick leaves, etc., for which the New Haven association seems to provide in an unusually fair manner. Also, one finds that salary rates are continually changing, so that what was an average minimum for 1926 would not be so in 1927.

Therefore, the most rational basis for consideration would seem to be an actual study of the situation here in relation to the supply of desirable nurses, the demands of the work, the problem of staff turn-over and the cost of living in this community. We would suggest a shorter probationary period, an increase at the end of the first three months and the maximum beginning with the third year of service.

Department of Eome Economics. One of the most interesting and important phases of the work of the Visiting Nurse Association is the department of Home Economics with its staff of a supervisor and assistant and five visiting housekeepers, which has been treated in some detail in Chapter XVIII. In 1926 this department made 4,834 visits to assist in housekeeping and housekeeping problems, budgeted 124 families and made 722 home visits for instruction and advice in matters related to diet and the preparation of food. This department works very closely in cooperation with the nursing service, the dietitians acting as specialists in their field and the housekeepers helping to produce results in some of the most difficult situations. A study might well be made as to the desirability of laying greater emphasis on the nutrition rather than the home economics phase of the program and working in this regard more through the nursing staff itself than is at present the practice.

4. The Crippled Children's Aid Society. The general organization of the Crippled Children's Aid Society has been discussed in a preceding chapter (XIX).

The nursing service of the organization appears to be of the highest quality and will be strengthened by the greater emphasis on home physiotherapy now in process of development. The record system, on forms recommended by the National Organization for Public Health Nursing, supplies fairly complete case records for each patient, including necessary social data.

From the standpoint of nursing service, it seems unfortunate that the work of the Society's nurses should be isolated from the rest of the public health nursing service of the community. Experience has demonstrated again and again that efficiency is vastly increased when a specialist likes Miss Besom works, not alone, but in cooperation with a generalized nursing service, teaching a large group of district nurses to render ordinary routine services and dealing herself with the more complex cases.

5. New Haven Dispensary Nursing.Since we are including in this survey the work of the nurses in the City Venereal Disease Clinic, and since the work of the nurses in the various clinics of the New Haven Dispensary is being developed along similar lines in the closest cooperation with public health activities of the community, it seems desirable to include a brief report of these services, as they relate to other community work.

The Nursing Staff at the New Haven Dispensary represents a practically unique situation in this country in that the head nurses in children's, tuberculosis, special medical (venereaI disease), medical, surgical and women's clinics are graduate nurses with a background of experience in public health work and consider their work as a part of the community public health activities. The object of their work in the clinics, as expressed in one of their reports, is "to give a good nursing service in the clinic, to foIlow the patient in his home through cooperating with public health and social agencies, when indicated, and to keep in touch with him in the hospital, should his condition warrant hospitalization. "

Therefore the following report of outgoing communications from the nurses of the department seems to us interesting, as indicating the possibilities for the developmentof this type of nursing service in clinics which cooperate with community public health agencies:

July 1, 1926 to June 30,1927.

An analysis of the written communications from the Nursing Service to the Dispensary and outside agencies is as follows:

NEW HAVEN CITY DEPARTMENT OF HEALTH.

NEW HAVEN VISITING NURSE ASSOCIATION.

ALL OTHER AGENCIES.

One monthly report indicates that contacts were made with 11 different nursing groups, 8 social organizations, 4 sanitariums, 1 health officer, 1 department of education, and numerous private physicians.

Reports coming from outside agencies relating to the patients are not communicated directly to the clinic nurse. This fact greatly interrupts the continuity of service between the community nurses and clinic nurses.

6. The Queen's Daughters Association of New Haven. In June 1926, Professor Hiscock made a survey of this association at the request of the Committee on Social Work of the New Haven Community Chest. Since his report covers much of the material needed for the survey in relation to its nursing activities, we are taking the liberty of quoting from Professor Hiscock's report as follows:

The association was organized in June 1903 for the primary purpose of assisting the Sisters of the Holy Ghost in nursing the sick poor and in looking after " the spiritual, corporal and intellectual welfare of poor Catholic children." There were no visiting nurses at this time in the city. For three years four Sisters were employed, but since that time only two have been maintained.

The work of the association as outlined in the 1925 booklet of the Community Chest is as follows:

"This association assists the two Sister nurses in keeping a supply closet of clothing and other articles needed in their work, and is also supervising a visiting housekeeper, who is carrying aid, direction and kindly advice to many homes who need her. Many children, hitherto kept away from school by 'little mother' duties, are relieved by it and returned to their studies. "

The Sisters do their work in New Haven, East Haven, Westville, West Haven, and Hamden. As above stated, one visiting housekeeper is employed for the same territory. The work is not confined entirely to any one group or religion, although the majority of cases are among Catholics. Before undertaking the field visiting, and during the evening, the nurses render such nursing care as is necessary to the young women living at St. Joseph's Convent. The salary of each of the two Sisters who do home visiting is $110 a month, exclusive of room and board provided by the Convent. The organization of the Queen's Daughters has a paid up membership of 100, but approximately 150 other friends assist in card parties and in Christmas sales which are held to raise funds in addition to the $3,420 supplied by the Community Chest ($3670 for 19281. The total budget of the Queen's Daughters in 1926 was $4,420.

The scope of work of the Association is indicated by the fact that in 1925 the Sisters made 4552 visits to 220 families while the housekeeper made 1200 visits to 16 families which indicates an intensive type of service. The majority of cases cared for by this organization are old people, frequently involving special problems which occupy the attention of the Sisters while they are giving nurse care. It will be noted that an average of over 20 visits is made yearly to each patient. In fact, the actual number of visits to patients is greater than this figure because there are frequently two or more patients in one family, and consequently the number of families served is less than the number of patients above indicated. It is also noteworthy that an average of from 75 to 84 visits by the visiting housekeeper are made annually to each case served.

Because of the pressure of work and the lack of clerical assistance, the patients visited are not classified according to cause of illness or reason for visit. In order to obtain a clearer picture of the type of cases visited by the nurses and of the service rendered, a personal visit was made on Thursday, June 24th, 1926, with the sister nurses to a group of cases considered typical, eight in number. These cases made up approximately one-fourth of the total cases under care. All of the cases seen were suffering from chronic complaints and five were in bed, while all but one of the eight were apparently helpless. All were old people. The visitor was impressed with the devotion to duty of the Sisters and with the confidence of the patients in ,the service rendered. Approximately two-thirds of the cases were distinctly needy cases, while the remainder were in families apparently just able-to meet their current expenses.

The relation of the Queen's Daughters to other organizations in the city seems to be cordial, although not intimate. The nurses from time to time refer cases to physicians, to dispensaries and to hospitals, but the number thus referred in a given year is not available. It is not their practice to take over a case which is being carried by another nursing organization, except in rare instances when some special reason is indicated and they are requested to do so. Undoubtedly, certain types of cases, psychologically and otherwise, respond to the care given by the Sisters more readily than to any other available service. It is also interesting to note that certain of the patients visited expressed their particular desire to have these Sisters visit them in preference to other nurses because this insured the visit of the same nurse from day to day.

It appears that this is an organization of long standing which maintains a limited nursing staff particularly desired and utilized by special groups of the city. The nursing staff of the Queen's Daughters is confined largely to chronic cases, necessitating an intensive type of service, although acute eases are also cared for upon request. Furthermore, this service combines bedside nursing care, social service work, and relief. It seems fair to state that from one fourth to one third of the time of the sisters is spent in social service work and in rendering relief to needy patients, rather than in what may be strictly considered as nursing. Many of the cases visited require considerable assistance in the way of food and cIothing. The clothing is delivered by the sisters, while much of the food is distributed to the families from the Convent and paid for by the Queen's Daughters.

7. Private Duty Nursing. Since a large proportion of the population of New Haven is able to use the services of full time private duty nurses and attendants, it seemed desirable to include some statement of this situation as it obtains in New Haven.

On January 26, 1928 the Central Registry for Nurses listed:

216 graduate nurses, 116 undergradutes.

Of these, on February 14, usually a busy time of the year, -40 graduates were unemployed (nearly one-fifth); 12 undergraduates were unemployed.

The Registrar states that in her estimate there is more than an adequate supply of nurses to meet the needs of this community except under unusual circumstances. It was necessary for this registry to refuse only 180 out of 5,239 calls last year. This represented no special group of cases except possibly communicable diseases. Many nurses refuse these cases when they have had no special training in them during their nursing course.

This condition of over supply is in accord with the findings of the National Committee for the Grading of Nursing Schools. A recent study of the supply and demand of nurses indicates that except for a very few sections there is a larger supply of nurses than the number for whom it is possible to find adequate employment.

8. Conclusions and Recommendations.

Health Department Nursing. The health department nurses are doing an excellent piece of work in the schools of New Haven, cooperating in an unusually effective manner with the other nursing agencies of the city for the benefit of school children.

School nursing is apparently one of the most difficult of special fields in public health. It requires cooperation, not only with the usual community agencies related to the home, but especially with the groups interested in the child in school, it demands very special knowledge of certain educational problems as well as rather unusual capabilities. In few places has it developed to the extent of its seeming possibilities, therefore, these recommendations relate more to the great opportunities of this field of work than to any defects in the present program.

Relations between the Health Department and the Visiting Nurse Association. It has been pointed out that two years ago the HeaIth Department delegated its tuberculosis nursing to the Visiting Nurse Association with admirable results in the promotion of efficiency and economy. It is suggested that the same course might well be followed in regard to the welfare nursing of the department. These two types of nursing service are essentially akin to the routine home service of the Visiting Nurse Association and mav be logically differentiated from such work as that of the communicable disease and venereal disease nurses, which is largely of a regulatory nature and from that of the school nurses which is to a large extent carried on in the schools rather than in the homes. We believe that it is entirely reasonable for the city, while retaining its ultimate and inalienable authority, to secure the performance of particular functions by volunteer organizations acting as its agents; where, as in the case of home nursing and polyclinic service, there are marked advantages is such a course.

If, however, the city is thus in increasing degree to make financial appropriations for the carrying on of health activities by volunteer agencies such as the Visiting Nurse Association, it is essential that machinery should be provided by which it may be rendered certain that the city knows what it is gethng and gets what it needs. The city, while it may properly be prepared to delegate the execution of any of its functions so long as such a course is profitable, must, of course, be able to terminate the agreement at any time and must be able to inform itself from day, to day as to the extent to which its needs are being met. In order to attain this end in the case under consideration, we would make the following recommendations.

Visiting Nurse Association. After studying the history and work of this organization one cannot but agree with the feeling which prompted Dr. Patterson of the National Tuberculosis Association in summarizing his report of the work of this Association in the tuberculosis field, to say, "Your investigator has conferred with nursing associations and observed their work in numerous communities. He knows of no other association so well organized and administered as the New Haven Visiting Nurse Association."

In recommending that certain nursing activities now carried on by other services be given over to the generalized program of the Visiting Nurse Association or more closely linked with it, a great responsibility is being put upon this organization to maintain in its enlarged program the advantages of the smaller and more individualized pieces of work.

In order to do this adequately it should be the goal of the organization to obtain the help of specialists in each service it is maintaining, and for which specialized work has been developed. Already the organization has two specialized supervisors in tuberculosis and in the combined fields of child welfare and maternity. It would seem desirable to expand this aspect of the work to have one supervisor each in the Maternity and Infant Welfare fields. Among the newer and most successful developments in specialized supervision has been that in the field of mental hygiene. A notable example of this is to be found in the work of the Boston Community Health Association which at the present time has two mental hygiene supervisors. These supervisors in Boston have found their work through the nurses' contact in the home a most satisfactory way of dealing with early mental cases. It may be that through the development of this work one of the most dificult and increasingly important problems of public health (the early detection and treatment of important mental deviations) will be met, and it is certain that the staff nurse would find a mental hygiene viewpoint invaluable in the conduct of her daily work. It would seem very desirable, therefore, that such a worker should be added to the Visiting Nurse Association staff. The hearty cooperation of the Society for Mental Hygiene could be counted on in such a development.

It seems to us that the success of generalized nursing, carried out by a relatively large staff of professional workers depends not only upon the administrative policies as such, the type and amount of supervision, and the qualifications of the staff members, but also upon the extent to which individual nurses are permitted and stimulated to contribute to the development of the work along the lines of their own special interests and capabilities.

Crippled Ghildren's Aid Society. The highly important service performed by this society in the field of orthopedic nursing would be greatly strengthened by closer afflliation with the generalized home service of the Visiting Nurse Association.

We would therefore urge as

Queen's Daughters. In our visits with the Sisters of the Queen's Daughters, it was very evident that their contact with their patients was excellent and that they had been providing help to certain chronic cases for years in a way which has brought great comfort to these people and doubtless has often made possible the maintenance of a home. One case visited, of chronic arthritis, has been on the lists over fifteen years with almost daily visits a great part of the time. The Sisters have no fixed rule in relation to whether the patient is under the supervision of a physician or not. Several cases have had no physician for several years (everything possible apparently having been done previously). A certain number of the cases, on the other hand, are acute illnesses, in which the services required are those of the usual visiting nurse type.

The problem of the chronic case in visiting nurse work is always a vexing one. In combination with a program for the care of acute cases, child welfare work; etc. the chronic case often seems to take a relatively large amount of time away from the more educational and highly skilled or specialized work of the public health nursing association. Sometimes during periods of stress these chronic cases may be somewhat neglected.

In view of these facts, it appears that the Queen's Daughters are performing a highly useful function, but it would seem desirable that an attempt be made to develop some more definite plan of cooperation with the Visiting Nurse Association by which certain types of chronic cases might be referred to the Sisters from the Visiting Nurse Association and acute sickness and all cases of tuberculosis or child welfare work for which the Visiting Nurse Association maintains specialized supervision should be referred by the Queen's Daughters to the Visiting Nurse Association. In this plan some consideration might also be given to a distribution of cases which will tend to lessen the travel over a widely separated area on the part of the Queen's Daughters. This should be possible since of necessity the Visiting Nurse Association will still continue to carry a considerable number of chronic cases as in the past.

Recommendation 75. That the Queen's Daughters and the Visiting Nurse Association work out a cooperative plan by which certain types of chronic cases are referred by the Visiting Nurse Association to the Queen's Daughters and other types of cases for which the Visiting Nurse Association is especially well equipped to care, are referred to the Visiting Nurse Association by the Sisters.

General Recommendations:

Cooperation. The spirit of cooperation between the various nursing organizations and other social agencies in the city seems to be splendid. However, there is no definite plan by which the various public health nurses may meet at stated intervals to discuss their problems and plan for closer team work. Therefore:-

Recommendation 78. It is recommended that a Joint Council of Community Nursing be organized which shall include the City Health Department nurses, the Visiting Nurse Association nurses, the Crippled Children's Aid Society nurses, the Queen's Daughters' nurses, the Dispensary nurses, and representatives of the three schools of nursing, with the purpose of making possible better understanding of community problems and better methods of cooperation.

Occupational Therapy. At the present time there is no provision in New Haven for occupational therapy work under trained supervision, although in hospitals or in homes this need is felt to be a very important one in relation to nurses' work with chronic and convalescent cases, especially in the orthopedic field.

Recommendation 80. Therefore, it is recommended that the Connecticut Occupational Therapy Society be invited to make a study of the situation with a view of analyzing the need and possible facilities for such work, both in the community and in the hospitals.

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